Slide 1

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 2

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 3

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 4

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 5

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 6

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 7

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 8

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 9

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 10

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 11

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 12

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 13

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 14

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 15

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 16

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 17

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 18

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 19

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 20

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 21

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 22

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 23

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 24

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 25

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 26

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 27

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 28

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 29

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 30

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 31

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 32

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 33

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 34

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 35

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 36

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 37

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 38

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 39

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 40

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 41

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 42

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 43

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 44

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 45

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 46

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 47

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 48

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 49

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 50

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 51

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 52

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 53

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 54

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 55

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 56

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 57

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 58

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 59

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 60

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61


Slide 61

Research Focused
on Real Treatment
Presentation at “2007 National Association of
Addiction Treatment Providers (NAATP) Conference”,
May 20-23, 2007, San Diego, CA. The opinions are
those of the authors and do not reflect official
positions of the association or government. Available
on line at www.chestnut.org/LI/Posters or by
contacting Joan Unsicker at 720 West Chestnut,
Bloomington, IL 61701, phone: (309) 827-6026, fax:
(309) 829-4661, e-Mail: [email protected]

The Panel









Michael L. Dennis, Ph.D. Director, GAIN
Coordinating Center, Lighthouse Institute, Chestnut
Health Systems, Bloomington, IL
Cara Renzelli, Ph.D., Director of Research and
Evaluation, Gateway Rehabilitation Center,
Pittsburgh, PA
Sigurd Zielke, Ph.D., Clinical Specialist
(Adolescents), Fairbanks , Indianapolis, IN
Valerie J. Slaymaker, Ph.D.,Director, Butler Center
for Research, Hazelden, Center City, MN
Erin Deneke, Ph.D., Director of Research, Caron
Treatment Centers, Wernersville, PA
Susan Gordon, Ph.D., Research Director, Seabrook
House , Seabrook, NJ
2

What do we mean by research?


Management by objectives and milestones (budget,
plans, internal funds)



Performance Monitoring (e.g, Oryx, NOMS, GPRA,
internal and external funds)



Group problem solving to improve performance
overal or for a subgroup (e.g, NIATX, Drug Courts)



Program Development and Evaluation (e.g., Private,
state or CSAT grants)



Development and Replication of Evidenced Based
Practices (e.g., CSAT, NIH grants)



Quasi-Experiments and Randomized Experiments
(e.g, NIH grants)
3

As you move down this list


It requires better and more consistent leadership, communications,
and trust (particularly for a problem solving type approach)



Often requires patient or staff incentives as the burden goes up



Often requires building of infrastructure (workforce, equipment,
systems) or changes in organizational culture that may take several
years to be completed



The level of staff qualifications and experience goes up (typically
from MA to Ph.D. with prior experience/grants)



The types of funding shifts (from direct service to state/foundation
to CSAT to NIH)



The time to get funding gets longer and the likelihood of funding
goes down (e.g., NIDA/NIAAA only fund the top 10-13% of
applicants and that typically takes 1.5 to 2 years to get from the time
the proposal is submitted)



May require collaboration with outside vendors (e.g. to help
implement an evidenced based practice) or experts (e.g., in a specific
analytic technique)

4

Cara Renzelli, Ph.D.,
Director of Research and Evaluation,
Gateway Rehabilitation Center
Gateway Rehabilitation
Center’s mission is to enable
people affected by or at risk
of addictive diseases and
other mental and emotional
disorders to lead healthy and
productive lives through
prevention, education,
treatment, and research.
5

Gateway’s Range of Services






Genesis
– Prevention
– Evaluation
– Detoxification
– Inpatient
– Outpatient
Extended Care
– Halfway Houses
Corrections
Ohio – Neil Kennedy Recovery Clinic
6

Research Activities - Internal Projects


Study of detoxification medication



Exploration of gambling problems in our
treatment population



Evaluation of teen leadership institute



Development and implementation of
outcomes monitoring system



Assists on performance improvement
initiatives
7

Research Activities - External Projects
Gateway has long history of collaboration with
university-based research…recent endeavors include


1980s & 1990s – Washington and Jefferson College
and Indiana University of Pennsylvania: inpatient
and outpatient treatment outcomes



1992 – today – University of Pittsburgh Medical
Center, WPIC: Pittsburgh Adolescent Alcohol
Research Center



2003 – 2005 – University of Pittsburgh, School of
Social Work: study of adult outcomes and
spirituality



2006 – present – Washington University, School of
Medicine: prescription abuse study

8

Development and Implementation
of Outcomes Monitoring System


Need for outcome data (Why measure?)



Domains (What to measure?)



Time points (When to measure?)



Staffing needs (Who will measure and where?)



Practical applications (How will we use the
data?)

9

Outcomes Monitoring System


Why we decided to create this system



Time points
–
–



Data collected on ALL patients at 1, 3, 6, 12, and 24
months after discharge from final level of care
Collected by phone, mail, or personal interview

Domains
–
–
–
–
–
–

Demographic – marital, employment, education
Criminal justice involvement
Additional post-discharge treatment
Relapse/abstinence
12-step participation
Quality of life
10

Outcomes Monitoring System


Staffing needs - Currently have one research
director, one research assistant (RA), and a team
of volunteers
–
–
–



All volunteers trained on basic research principles,
data integrity, confidentiality
RA and volunteers collect data
RA manages collected data

Quiet, private space required

11

Outcomes Monitoring System


Practical applications
–

Provides a picture of patients’ functioning
after they leave our care

–

Allows us to look for trends in the data that
alert us to investigate further or take action

–

Gives other departments within the Gateway
system information that may meet a general
or specific need

12

Future Directions of the
Research Department


Increase the number and breadth of our inhouse research and evaluation studies



Expand outcomes system to begin assessments at
admission, during treatment, and at discharge



Expansion of survey domains



Continue our work with university-affiliated
researchers



Form collaborations with other treatment
facilities to seek funding for multi-site projects



Extend dissemination efforts
13

Sigurd Zielke, D.Min.
Clinical Specialist (Adolescents)
Fairbanks
Fairbanks is a nonprofit
organization focused on
recovery from alcohol and
other drug problems,
serving as a resource to
improve the well-being of
individuals, families and
communities by offering
hope and support through
its programs and services.
14

Objectives


To construct empirically-informed models and
generate methods to enhance adolescent
treatment and recovery support



To create an evidence-informed mindset among
our clinicians i.e., an evidence-informed clinical
culture



To secure external partners for the
measurement of models and methods
generated
15

Full Range of Adolescent Services


Discovery (education)



Detoxification



Rehabilitation



Residential



Transitional Living



Partial Hospitalization



Intensive Outpatient



Recovery Management I & II



Hope Academy (Recovery High School)
16

Challenges to Adolescent Treatment &
Recovery Support


Historic application of adult models of treatment and
recovery to adolescents



Recent recognition by health services researchers…
“that adolescence is different from adulthood, and that
the methods to identify, treat, and prevent illness need to
be different” (Zucker, 2006)



Emergence of the new field of developmental
psychopathology



Explosion of neurobehavioral research



Lack of coherent adolescent treatment and recovery
support models that integrate 12-step recovery processes
with recent neurobehavioral and developmental findings



Need for empirical study of updated models
17

D ia th e s is -S tre s s M o d e l: B io p s y c h o s o c ia l-D e v e lo p m e n t a l
“A m a jo r p re m ise … is th a t ad ult diso rd e r d o e s n o t e m e rg e full-blo w n in a d ulth oo d , bu t ra th e r is a p ro ce ss tha t e m e rg e s o ver ti m e , a n d
fo r w h ich childh oo d pre curso rs a re likely to b e ide n tifia ble .” (Z u cke r, 2 0 00 ; D e velo pm e n ta l P sych o p a th o log y)

1 . M u st co n sid e r th e m u ltip le (cu m u la tive ) risk fa c to rs a n d
ca u sa l lin k s e m e rg in g o ve r tim e .
D ia th e sis

V ulnerability.—

a tendency to suffer from a
certain condition

R isk F a cto r
T ra n sa ctio n a l
E ngagem ent

2 . R o o ts o f la te r d iso rd e rs ca n b e
fo u n d in e a rlie r p ro b le m s th e
in d ivid u a l m a y h a ve h a d in re s o lvin g
m a jo r d e v e lo p m e n ta l issu e s.

P rim a ry
D ia g n os tic
S yn d ro m e

O ve r T im e
C a u sa l L in k s

R is
e
tiv
a
l
mu
u
fC
o
s
res
t
S
is s
e
th
a
i
D

P ro te ctive F a cto r

k

to
Fac

rs
C o -O ccu rring
D ia g no stic
S yn d ro m e

C o -O ccu rring
D ia g no stic
S yn d ro m e

O ve r T im e
G e n o typic - Lo a d

G e n e T ra n scrip tio n

P h e n o typic

© C op yrig ht Z ielk e & Z ielk e, 2 0 04

18

O ur S tra teg y

C h a n g in g D e v e lo p m e n ta l P a th w a y , B ra in
O rg a n iz a tio n & S ta te s o f C o n s c io u s n e s s
Zielke, 2005

D ia th e sis
V u ln e ra bility
T ra n sa ction al
E n g a ge m e n t
R isk F a cto r

1 . A u d it a ss e ts e m b e d d e d in risk
p a th w a y.
2 . “R e lo a d ” a u d ite d a sse ts a lo n g a n
a lte rn a tive p ro s o cia l p a th w a y (th is
a m e lio ra te s re sista n c e ) a n d th e n
b o lste r w ith a d d itio n a l a sse ts.

P rim a ry
D ia g n o s tic
S yn d ro m e

P ro te ctive F a cto r
O
O ve
ve rr T
T im
im e
e
T ra n sa ction al
C
E na gu asal
ge Lin
m eks
nt

R is
e
v
la ti
A
N lte
e wrnPaative
th w P
a ya th w a y
u
um
C
of
s
s
tr e
S
s
esi
h
t
D ia

k

to
Fac

rs

C o -O ccu rring
S yn d ro m e
C o -O ccu rring
S yn d ro m e

O ve r T im e
© C opyright Z ielke & Z ielke, 2004

19

Research Needs (i.e., Targets)


Need for grounded identification of adolescent
treatment, relapse and recovery issues (affirmation of
practitioner knowledge)



Need for extensive professional literature reviews



Need for rigorous theoretical research—resulting in
grounded, empirically-informed models



Need to develop methodologies to enact models



Need for clinical staff to utilize models/methodologies



Need to establish “fidelity standards”



Need to secure academic partners to measure the
efficacy of the models/methodologies generated
20

Research Response: Projects









Grounded video study of student behavior; over 2000
classrooms in light of neurobehavioral literature
Focus group narrative analysis study of educators
experiences with young students coming to school SI
Joint hospital and university 2 year professional study of
the literature on SI children/youth, addiction brain
studies, and pathway findings
A field-based action research study to enhance the school
behavior of SI elementary students: grades one through
five—test of preliminary models
Theoretical research---NBD White Paper (July 2007)
Generation and utilization of empirically-informed
methods:
- 90 in 90: A Recovery Tool for School Success
- Node link mapping of student relapses



Establishing collaborations with academic/research
partners
21

Creating An Evidence-Informed Clinical Culture for
The Treatment And Recovery Support of Adolescents

8. Share results:
publication &
training

1. Identify/target
clinical issues of
persistent concern

7. Use data to affirm,
amend, or disregard
models/ practice

6. Conduct quality
improvement and pilot
studies with external
collaborators

2. Conduct
field/grounded study
of targeted concern
to discern patterns
of functioning

3. Identify strong lines
empirical evidence
that address
targeted concerns

5. Use models to
guide practice and
create tools

4. Synthesize findings
of 2 and 3 into field
theory and models
of practice

Critical Cultural Elements

• Identify “curious” clinicians
• Carve - out 1hr per week
• Keep collegial

• Keep multidisciplinary
• Provide readings
• Tie to writing and training

22

Valerie J. Slaymaker, Ph.D.,
Director of Hazelden’s
Butler Center for Research (BCR)
Dedicated to improving recovery from
addiction by conducting clinical
and institutional research,
collaborating with other research
centers, and communicating
scientific findings.

23

BCR Structure


Two doctoral-level research staff



One FT research assistant (others as funded)



Data collections staff

24

BCR Activities


Institutional research and evaluation



Clinical research and collaboration



Consultation



Knowledge dissemination

25

Institutional Research & Evaluation


Outcomes data collection & reporting
– 1, 6, and 12 month follow-ups
– Use and functional outcomes



Special populations and reports
– BCBS
– Methamphetamine Outcomes Study
– Family Program
– Scale development

26

Clinical Research & Collaboration


Milestones of Recovery studies



Phone-based Case Management



Huss Research Chairs on Late Life Addiction



Youth, AA and Treatment Processes study



University of Minnesota Youth & Neuroimaging
study

27

Knowledge Dissemination


Research Update



Substance Abuse Research Forum



Dan Anderson Research Award



Conference presentations



Published manuscripts

28

Erin Deneke, Ph.D.,
Director of Research
Caron Treatment Centers
?? Mission
Or Logo

29

Range of Services


Inpatient Care –
– Men’s Primary
– Women’s Primary
– Adolescent
– Relapse
– Young Adult Male Program (YAMP)



Extended Care –
– Men, Women, and Adolescents



Family Education Program



Center for Self-Development



Caron Outpatient Counseling
30

Current Research Activities


Focused Continuing Care
–



Chronic Pain Study
–

–



In collaboration with Treatment Research Institute
In collaboration with University of Pennsylvania and
Reading Hospital
Funded by NIDA

Chronic Pain sub-study
–

In collaboration with Reading Hospital



Menstrual cycle and cravings study



Menopause and addiction study
31

Caron Research Staffing


Director of Research –
–
–



Research Administrator –
–
–
–



Participant recruitment and data collection
Data entry
Assist with literature reviews

Research Committee –
–
–
–



Design , develop, coordinate, and implement intramural and extramural
research projects.
Data analysis, reporting, publishing, and presentations

Review ongoing studies and outcomes
Evaluation of new or proposed projects – advantages/disadvantages
both for internal as well as external studies
Act as an informal Human Subjects Review Board – all projects would
be approved through committee for implementation at Caron.

Physician’s Advisory Committee –
–
–
–

Cutting edge treatment practices
Best research methodology
Members include: Charles O’Brien, M.D.; David Mee-Lee, M.D.;
Hoover Adger, M.D.; Sheila Blume, M.D., C.A.C.
32

Focused Continuing Care


Available to all patients once leaving inpatient treatment
– Adult only at this time
– Will move to adolescent units



Monthly follow-up contacts by phone for 12 months by focused
continuing care specialists (5)
– Check in with patients to see how they are progressing in their
recovery
– Data collection on such variables as AA attendance, sponsorship,
mental health issues, follow-up care, and family issues



Ability to analyze data at various points through 1 year post treatment



Outcome oriented
– Both quantitative and qualitative data



Provide information on possible programmatic changes



Unit specific data

33

Moving towards the Future


Increase the number of intramural projects occurring at
Caron



Increase collaboration with other agencies and
universities



Encourage more extramural research activities



Increase number of sources for outside funding of projects



Improve dissemination of information through published
articles, conferences, presentations, and information
available to consumers



Assist in marketing and public relation endeavors by
providing media relevant information
34

Susan Gordon, Ph.D.,
Director of Research,
Seabrook House

“To help families find the
courage to recover.”

35

Seabrook Research Goals



Process and outcomes evaluation of two
residential treatment programs



Grant funding to increase/enhance clinical
programs



Participation in NIDA CTN

36

Seabrook Evaluation Project:
MatriArk Family Program


Residential treatment facility



Low income women and children



10 short-term (28 days) patients



37 long-term (6 – 12 months) patients



12-step treatment approach



Funded through state and local government

37

MatriArk Goals
In-treatment


Reunification of women with young children
during treatment



Increase healthy pregnancies and births

Post-treatment


Increase abstinence



Increase 12-step participation



Increase bio-psycho-social functioning
38

MatriArk Evaluation Goals
Assess all eligible and willing patients


–
–

Admission and in-treatment
Discharge and one-year follow-up for treatment
completers



Assess grant funding objectives



Identify strengths of the program



Identify aspects of the program to improve

39

MatriArk Research Infrastructure
PEOPLE: Staffing


Research Director
–
–



Research Assistant
–



Develop & implement project
Analyze results
In-treatment data collection and data entry

Aftercare Case Manager
–
–

Post-treatment data collection
Post-treatment needs assessment

40

MatriArk Research Infrastructure
PLACES: Facilities


Private office space for patient interviews, follow-up calls

THINGS: Resources


Computer, network and internet



Locked filing cabinets



Separate telephone line and stationery for follow-ups



Appreciation gifts for patient follow-ups

41

MatriArk Research Infrastructure
Protocols


Consent procedures



Post-treatment follow-up procedures
–



Staff training and certification
–
–



Locating difficult participants

Research ethics
Instrument administration

Safety protocol for home visits

42

MatriArk Research Infrastructure
Oversight


Research and Education Advisory Committee
–
–
–



10 SBH; 2 external members
Recommend research projects
Monitor ongoing research

No I.R.B.
–
–

Not Federally funded research
Not clinical trial

43

MatriArk Assessments


Evidence-based assessments
–
–



Clinically-useful assessments
–



Reliable and valid
Measure goals and objectives
Applicable for treatment

Appropriate “response burden”
–

Main task of patients is treatment – not research!

44

MatriArk Assessment Schedule
Instrument

GAIN

Admission

In-Treatment

Initial

Tx Satisfaction

Discharge

30 days

ASI

30-day
Follow-Up

90-day
Follow-up

Substance
Abuse

M90

Initial

DTCQ

X

Pregnancy
History

Full

SCL-90

X

PSI

X

TSPQ

X

UDS

X

30 days

90 days

X

X

Follow-up

Follow-up

X
X

X

X
60 days+

X
X
45

MatriArk Recruitment
Completed Follow-ups
100

96

100
91

% Eligible Participants

85

87

80

60

40

20

0
Admission
(55/57)

Discharge
(22/22)

1 month (17/20)

2 month (10/11)

3 month (7/8)

46

Michael Dennis, Ph.D.,
Director of the GAIN Coordinating
Center, Chestnut Health Systems
Improving the quality of human
service interventions through
applied research, publications, and
training.
- Lighthouse Institute Mission
Improving assessment to facilitate
evidence-based practices.
- GCC Mission

47

Chestnut’s
Direct Clinical
Services
FY05 Admissions
(n=9311) for Substance
Abuse and Mental Health
Services from 82 of Illinois
103 counties
FY05 Admissions
1,000 to 9,999
100 to 999
10 to 99
1 to 9
48

Chestnut Global Partners
International Employee Assistance

49

Chestnut’s
Lighthouse Institute
(Research Division)










Started in 1985 and grew to 90 full/part
time staff grossing $9 Million a year in
external funds (NIH, SAMHSA,
Foundations)
LI-Research: Several major
experiments, quasi-experiments and
major surveys
LI-Training and Publications: 100s of
training days and largest collection of
evidence-based treatment manuals
EBTx Coordinating Center---Supports
training, certification, and coaching of
clinicians and clinical supervisors
learning A-CRA and ACC
GAIN Coordinating Center – supports
training, certification and use of the
GAIN to support diagnosis, placement,
treatment planning, and research

LI-Research
Facilities
Major Study
Geog. Areas
50

LI’s Global Appraisal of Individual Needs
(GAIN) Coordinating Center (GCC)
`
NH

WA
VT
MT

ND

ME

MN

OR

MA
ID

SD

WY

WI

CA

CO
KS

MO

OH

DC

IN
KY

WV

OK

NM

AR

NJ
DC

AL

DE

MD

SC
MS

TX

VA

NC

TN
AZ

RI
CT

PA
IL

UT

MI

IA

NE
NV

NY

0
1 to 10
11 to 25
26 to 130

GA

LA

Statewide System*

AK
FL
HI
VI
PR
* Also being considered in FL, GA, NC, SC,
51 TN

Started by Bill
White to do
Training and
Evaluation

10,000,000
9,000,000

Created
GAIN
Coordinating
Center

8,000,000
7,000,000
6,000,000
5,000,000
4,000,000
3,000,000

Started going
for External
CSAT/ NIH
Funding

2,000,000
1,000,000
0
19
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
2099
2000
2001
2002
2003
2004
2005
2006
07

Lighthouse Institute Annual Revenue .

It took a lot of time to get here…

52

100%

80%

60%

40%

20%

0%

100%

Adolescents More likely
to have externalizing
disorders

80%

60%

40%

20%

0%

Multiple Co-occurring Problems are Correlated
with Severity and Contribute to Chronicity

Health Distress
Internal Disorders
Adults more
likely to have
internalizing
disorders[

External Disorders
Crime/Violence

Criminal Justice
System
Involvement
Adolescents
Dependent (n=3135)
Abuse/Other (n=2617)

Adults
Dependent (n=1221)

Abuse/Other (n=385)
Source: GAIN Coordinating Center Data Set

53

100%
90%

21+

80%

15-20*

70%

Percent in Recovery

60%

under 15*

50%
40%

Age of 1st Use Groups

Substance Use Careers are Longer,
the Younger the Age of First Use

30%
20%
10%
0%

* p<.05
(different
from 21+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
54

100%
90%

0-9*

80%

10-19*

70%

Percent in Recovery

60%

50%
40%

20+

Years to 1st Tx Groups

Substance Use Careers are Shorter
the Sooner People get to Treatment

30%
20%
10%
0%

* p<.05 (different
from 20+)

0

5

10

15

20

25

Years from first use to 1+ years abstinence

30
Source: Dennis et
al 2005 (n=1,271)
55

It Takes Decades and
Multiple Episodes of Treatment
100%
90%
80%

Percent in Recovery

70%

Median duration
of 9 years
(IQR: 3 to 23)
and 3 to 4
episodes of care

60%

50%
40%

30%
20%
10%
0% 0

5

10

15

20

Years from first Tx to 1+ years abstinence

25
Source: Dennis et
al 2005 (n=1,271)
56

Other Aspects of Recovery
1-3 Years:
1-12 Months: of Abstinence
3-5 Years: 5-8 Years:
by Duration
of 8 Years
Decrease in
Immediate
Improved Improved
Illegal Activity;
Psychological
increase in clean
Vocational and
Increase
in
100%
and sober friend
Financial Status Status
Psych Problems
90%

% of Clean and
Sober Friens

80%
70%

% Days Worked
For Pay (of 22)
% Above
Poverty Line

60%
50%
40%
30%
20%

% Days of Psych
Prob (of 30 days)

10%
0%
Using 1 to 12 ms 1 to 3 yrs 3 to 5 yrs 5 to 8 yrs
(N=661) (N=232) (N=127) (N=65)
(N=77)

Source: Dennis, Foss & Scott (under review)

% Days of Illegal
Activity (of 30 days)
57

The Cyclical Course of Relapse, Incarceration,
Treatment and Recovery: Adults
Avg of 32% change
status each quarter

P not the same in
both directions

Incarcerated
(37% stable)

6%

7%
25%

30%
In the
Community
Using
(53% stable)

8%

13%

8%

In Recovery
(58% stable)
29%
4%
44%

31%
In Treatment
(21% stable)

Source: Scott et al 2005

7%

Treatment is the
most likely path
to recovery
58

RMC’s Impact on Time to Treatment Re-Entry
100%

The size of the effect is
growing every quarter

Percent Readmitted 1+ Times

90%
80%

70%

630-246 = -384 days

60%

55% ERI-2 RMC*
(n=221)

50%
40%

37% ERI-2 OM
(n=224)

30%
20%
10%
0%

0

90

180

270

360

450

540

*Cohen's d=+0.41
Wilcoxon-Gehen
630 Statistic (df=1)
=16.56, p <.0001

Days to Re-Admission (from 3 month interview)
Source: Dennis & Scott, in press; Scott & Dennis, under review

59

RMC’s Impact on Adult Outcomes
100%

Months 4-24

Significant Increase in Abstinence

90%

OM
76%

80%

Percentage

70%

Final Interview

68%

60%

RMC
Broke the
Run

76%

Less Likely to be in
Need of Treatment

68%

57%

Less
Symptoms

49%

50%

RMC

46%

37%

40%

27%

30%

19%

20%

10%
0%
of 630 Days
Abstinent
(d=0.29)*

of 7 Subsequent
Quarters in Need
(d= -0.32) *

of 90 Days
Abstinent
(d= 0.23)*

of 11 Sx of
Abuse/Dependence
(d= -0.23)*

Source: Dennis & Scott, in press; Scott & Dennis, under review

Still in need
of Tx
(d= -0.24) *
* p<.05

60

Contact Information


Michael L. Dennis, Ph.D. Director, GAIN Coordinating Center,
Lighthouse Institute, Chestnut Health Systems
(720 West Chestnut, Bloomington, IL 61701, Phone: 309-820-3805, E-mail:
[email protected] , Web: www.chestnut.org/li)



Cara Renzelli, Ph.D., Director of Research and Evaluation,
Gateway Rehabilitation Center
(100 Moffett Run Road, Aliquippa, PA, 15001; Phone: 724-378-4461 x1104; Email: [email protected])



Sigurd Zielke, Ph.D., Clinical Specialist (Adolescents),
Fairbanks
(8102 Clearvista Parkway,. Indianapolis, IN 4625, Phone: 317-572-9318, E-mail:
[email protected] )



Valerie J. Slaymaker, Ph.D.,Director, Butler Center for
Research, Hazelden
(P O Box 11 (BC 4) , Center City, MN 55012-0011; Phone: 651-213-4746; E-mail:
[email protected] )



Erin Deneke, Ph.D., Director of Research, Caron Treatment
Centers
(Galen Hall Road, P.O. Box 150, Wernersville, PA 19565, Phone: 610-743-6242,
E-mail: [email protected])



Susan Gordon, Ph.D., Research Director, Seabrook House
(133 Polk Lane, Seabrook, NJ 08302, Phone: 856-455-7575, ext. 5803, E-mail:
[email protected] )

61