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Transcript of Planning for Effective Treatment Services and Implementing Change Dwayne Simpson VA Association of...
Planning for Effective Treatment Services and Implementing Change
Dwayne Simpson
VA Association of Community Services Boards:Workshops for MH/SA Directors CouncilMAY 6, 2010; RICHMOND, VIRGINIA
• DARP (1st US Study 1970s)• TOPS (2st US Study 1980s)• DATOS (3rd US Study 1990s)
300+ Studies Published on 65,000 Drug Users Treated
in over 300 Programs
www.DATOS.org
NIDA’s National Evaluations of Treatment Effectiveness
Process matters!!!
© 2010
No-Trt vs. Trt (Retention) Grps
% R
elap
se
Opioid Addiction and Treatment:A 12-Year Followup (Simpson & Sells, 1990)
© 2010
Intake Year 1 Year 2 Year 3 Year 6 Year 12
100
6150 45 43 48
83
28 20 18 19 12
Opioid Use Jail/Prison•75% had relapses (1+) and•Avg of 6 treatments each …
but
•63% had no daily opiate useor relapse for 3+ years,
and•55% had no daily drug use
or arrests in past year (Yr 12)
Change influences and process?
Backgrd & Needs
Drug useSeverity
TreatmentHistory
6-YearOutcomes
Yrs 6-12 Psycho-Social
Functioning
12-YearOutcomes
Path Analysis Study(Lehman et al, 1990)
• Needs• Response• Support
Reasons for Starting Daily Opioid Use• Euphoria, anxiety-reduction, relaxation (intra-individual) • Sensation-seeking and peer influences• Impressing others and showing “street toughness” (inter-personal)• Access to drugs (environmental)
Reasons for Continuing Daily Opioid Use• Euphoria, anxiety-reduction, relaxation (intra-individual)
(Inter-personal and peer influences diminished de-socialization)
Reasons for Stopping Daily Opioid Use (“Recovery”)• Tired of the hassle – “hitting bottom” (intra-individual)• Health/medical problems, religion ( re-socialization)• Special events – getting married, family needs (inter-personal)• Fear of jail/violence (environmental)
Opioid Addiction and Treatment:A 12-Year Followup (Simpson & Sells, 1990)
© 2010
Program Structure, Staff, & Leadership
“Cognitive” Tools to Connect Thinking-Action Steps
Psychosocial Services:Recovery Engagement and Life Skills
(RELS)
© 2010
• Motivation
• Readiness
• Thinking• Decisions
• Behaviors• Practice
Diagnose – Intervene – Repeat (& Monitor Progress)
SF SF SFShort
Forms
• Needs/Risks• Motivation
• Psycho-Social• Criminal Thinking
• Engagement• Changes
Follow-upOutcomes• Drug use• Crime• Social
Functions
Client Recovery Stages in Treatment Other Treatments
or Support
Networks
Early Engagement•
Participatio
n• Therapeutic
Relationship
TreatmentReadiness:• Needs-Risk• Severity• Motivation
TreatmentReadiness:• Needs-Risk• Severity• Motivation Early
RecoveryChanges in --• Thinking• Acting
Retention & Continuing
Change
“Adaptive” Treatment
Assessments of Client Needs/ProgressAssessments of Client Needs/Progress
Interventions (Behavioral & Cognitive)Interventions (Behavioral & Cognitive)
Simpson, 1995, 2001, 2004, 2006© 2010
Stages of TreatmentStages of Treatment
Retention& Change
Early Recovery
Changes in • Thinking• Acting
Early Recovery
Changes in • Thinking• Acting
EarlyEngagement•
Participation
• Therapeutic
Relationship
EarlyEngagement•
Participation
• Therapeutic
Relationship
TreatmentReadiness:• Needs-Risks• Severity• Motivation
TreatmentReadiness:• Needs-Risks• Severity• Motivation
Targeted Interventions (with “Mapping”)
for Adaptive Treatment Process
Orientation Re-Entry
MappingJourney
Workshopfor Men
Transitionto Re-entry
Using ClientAssessments
Mapping Care Plans
DownwardSpiral
Mapping ’12 Steps’
ParentingSkills
Workshopfor Women
Treatment A Treatment B
Preparingfor Change
GettingMotivated
CM/RewardStrategies
BuildingNetworks
BetterComm
HIV RiskReduction
UnlockingThinking
ReducingAnger
“TCU Mapping-Enhanced Counseling”
© 2010
TCU Mapping: A Visual Representation Strategy
Fam
ily Work
Applications Resea
rch
Fort WorthTexas
Dwayne
8Grand kids
Married& 3 Children
TCUNIDA Grant
s
AddictionStudies
Strategic
Planning
Prof of Psycholo
gyAddictio
nScientis
t
TreatmentEffectiveness
InnovationImplementation
Process FUOutcomes
Engagement
Readyto Chg
OrgFunctioning
WestTexas
IBR (1962
)
© 2010
Leadership
Mission
Conceptual
Integration
Innovation
Selections
CJ/Adolescent Services
Fired!!Retired!!
TCU Mapping: A Visual Representation Strategy
© 2010
www.ibr.tcu.edu
Info
rmat
ion
Exch
ange
Group
Discussion
Link
ing
Even
ts &
Cons
eque
nces
Decision-M
aking
Strategies
Cognitive science provides foundations for these visual
communication & decision-making tools (using “node-link mapping”)
Dansereau, Dees, & Simpson, 1994 (JCP)Dansereau & Simpson, 2009 (PPRP)
SelectedPresentations
IBR HOME PAGE
IBRA National Research Center
for addiction treatment studies in community and correctional
settings(over 600 free resource files
available)
DATOSDATOS
ProgramProgramProgram
StaffStaffStaff
ResourcesResourcesResources
ClimateClimateClimate
PatientPatientPatient
SeveritySeveritySeverity
ReadinessReadinessReadiness
SufficientRetentionSufficientSufficientRetentionRetention
Early Early EngagementEngagement
Early Early RecoveryRecovery
PosttreatmentPosttreatment
DrugUse
DrugDrugUseUse
CrimeCrimeCrime
SocialRelations
SocialSocialRelationsRelations
ProgramParticipation
ProgramProgramParticipationParticipation
TherapeuticRelationship
TherapeuticTherapeuticRelationshipRelationship
BehavioralChange
BehavioralBehavioralChangeChange
Psycho-SocialChange
PsychoPsycho--SocialSocialChangeChange
EvidenceEvidence--Based Treatment ModelBased Treatment Model
CognitiveCognitiveStrategiesStrategies
BehavioralBehavioralStrategiesStrategies
Social SkillsSocial SkillsTrainingTraining
Family &Family &FriendsFriends
SupportiveNetworks
SupportiveSupportiveNetworksNetworks
Personal Health ServicesPersonal Health Services
Social Support ServicesSocial Support Services
Simpson, 2001 (Addiction)
ProgramProgramInterventionsInterventions
ReadinessReadinessTrainingTraining
SUMMARY
TCU Mapping-Enhanced
Counseling
TreatmentProcess
Counseling Manuals
Corrections-Based
Treatment
NationalEvaluations
OrganizationalReadiness
AssessmentFact Sheets(with norms)
www.ibr.tcu.edu
• Overview of Adaptive Treatment
System & Conceptual Models
See Guide for New Visitors
• Guide to Intervention Manuals
• Guide to Assessment Forms
• Project Updates & Summaries
• Newsletters, Presentations, and Publications (Abstracts)
EVIDENCE
MANUALSFORMSEVIDENCE ABOUT IBR-TCUSTAFFPUBLICATIONSPRESENTATIONS PROJECTSNEWSLETTERS
OTHER LINKSWHAT’S NEW
SITE GUIDES:
“Visitors”700+/day
30 mins
Trea
tmen
t Sta
geC
linic
al T
opic
s
(Mot
ivat
ion,
Ang
er)
Spe
cial
Pop
s(C
J, W
omen
)
© 2010“Introduction to self-training” for TCU Mapping
Over 20 Manuals Available
© 2010
New! Mapping Atlas
Top 70 Maps !
NO Costs for TCU Manuals
Assessing Client Needs and Progress During Treatment
Stages of TreatmentStages of Treatment
Retention& Change
Early Recovery
Changes in • Thinking• Acting
Early Recovery
Changes in • Thinking• Acting
EarlyEngagement•
Participation
• Therapeutic
Relationship
EarlyEngagement•
Participation
• Therapeutic
Relationship
TreatmentReadiness:• Needs-Risks• Severity• Motivation
TreatmentReadiness:• Needs-Risks• Severity• Motivation
IntakeInterview(eg, ASI)
Short ID & Background
Risk Info
Fam/FriendsNetworks
Motivation(from CEST)
Psychological (from CEST)
Social(from CEST)
Criminal Thinking(CTS)
Engagement(from CEST)
Fam/FriendsNetworks
Psychological (from CEST)
Social(from CEST)
Engagement(from CEST)
Psychological (from CEST)
Social(from CEST)
Criminal Thinking(CTS)
“Short” TCU
Forms (with
Feedback Charts)
© 2010
Measures of Client Functioning
Joe et al, 2002; Simpson, 2004 (JSAT): Simpson & Knight, 2007 (CJB)
Social Functioning• Hostility• Risk Taking• Social Support• Social Desirability
Psychological Functioning• Self Esteem• Depression/Anxiety• Decision Making• Expectancy
Treatment Engagement• Satisfaction • Rapport • Participation• Peer Support
Motivation• Problems• Desire for Help• TX Readiness•
Needs/Pressures
Criminal Thinking
•Entitlement•Justification•Irresponsibilit
y•Power
Orientation•Cold
Heartedness•Rationalizatio
n
© 2010
TCU Short Forms for Client Assessments
A. Client Drug Use and Crime Risk Forms:1. TCU Drug Screen II (DRUG SCREEN II) 2. Global Risk Assessment (A/Y-RSKFORM) 3. Criminal History Risk Assessment (CRHSFORM) 4. Criminal Thinking Scales (CTSFORM)
B. Client Health and Social Risk Forms:5. Physical and Mental Health Status Screen (HLTHFORM) 6. Mental Trauma and PTSD Screen (TRMAFORM) 7. HIV/Hepatitis Risk Assessment (HVHPFORM)8. Family and Friends Assessment (A/Y-FMFRFORM)
C. Client Evaluation of Self and Treatment (CEST) Forms: 9. Treatment Needs and Motivation (MOTFORM) 10. Psychological Functioning (PSYFORM)11. Social Functioning (SOCFORM)12. Treatment Engagement (ENGFORM)
© 2010
These are interrelated, and they CHANGE over time…
50%
© 2010
Interpreting Client Intake Scores
“Short” TCU
Forms (with
Feedback Charts)
SEE “USING CEST GUIDE”
Monitoring Client Scores Over Time
Simpson et al., 2009 (JSAT); Best, Day et al., 2009 (EAR); Joe et al., 2010 (JSAT)
Counselor Skills/Attributes
Organizational Functioning
Motivation Desire for Help Trt Readiness
.39.52
Self Esteem Depression.31 -.18
Peer Support Social Support
.48 .37
Risk Taking Social Conscious
-.24.43
(n=998)
TreatmentEngagement• Participation• Rapport• Satisfaction (CEST Scales)
Client functioningimproves over time,and the negative
impact of high CTS is“remediated” by
stronger engagement!
© 2010
Core Ingredients of “Effective System”
1. Conceptual framework for treatment process
2. Assessments of client functioning (CEST/CTS)
3. Manuals for “mapping” brief interventions:
• Motivation/thinking engagement
• Care planning & skills training
4. Publications for showing “evidence-base”
5. Implementation principles for organizations
6. Field network of innovation “ready adopters”
© 2010
Innovation Implementation
Stages of Implementation Process
4.Practice Improvement• Outcomes• Services• Budget
4.Practice Improvement• Outcomes• Services• Budget
3.Implementation•Effectiveness•Feasibility•Sustainability/Cost
1.Training•Relevance•Accessible•Accredited
2.Adoption A. Decision• Leadership• Quality/
Utility• Adaptability
B. Action• Capacity• Satisfaction • Resistance
Simpson, 2002; Simpson & Flynn, 2007 (Special Issues of JSAT); Simpson, 2009
Organizational Readiness & Functioning
Motivation ProgramClimate
StaffAttributesResources Costs
© 2010
Review of Facilities Management and
Services Flow
Review of Clinical Model for Care
Planning
Survey of Staff Needs and
Functioning
Strategic Planning for “Ready Adopters”
ORC Scales ORC Scales
Organizational Readiness for Change (ORC)
Simpson, 2002; Lehman et al, 2002 ; Simpson & Flynn, 2007 (JSAT)
Resources:• Offices/Staffing• Training• Equipment•
Supervision/Mgmt*
StaffAttributes:• Growth• Efficacy• Influence• Adaptability• Satisfaction*
Motivation:• Program
Needs• Training
Needs• Pressures
“Better organizations”
provide “better
services”
Climate:• Mission• Cohesion• Autonomy• Communication • Stress• Open to Change
© 2010
Ready for Change?
Climate: Cohesion of Staff (Scale scores range = 10-50)
Similar for other ORC measures
45 Programs (ITEP/BTEI Projects)
Lowest
Highest
25%Norm
75%Norm
50% of Programs
UK (Italy & US)
23
35
45
NTA ITEP/BTEI Projects (2006-07); Simpson et al., 2009 (JSAT)© 2010
Batch 24 3/12/2009 © Copyright 2009 TCU Institute of Behavioral Research, Fort Worth, Texas. All rights reserved.
ORC Mean Scores for 4 CJ ProgramsAgency Needs/PressuresSN – Staff NeedsPN – Program NeedsTN – Training NeedsPC – Pressures Change
ResourcesOFF - OfficesSTF - StaffingTRN - TrainingEQP – EquipmentINT – InternetSUP - SupervisionStaff AttributesGRO - GrowthEFF – fficacyINF – InfluenceADP - AdaptabilitySAT - SatisfactionOrganizational ClimateMIS – MissionCOH – CohesionAUT – AutonomyCOM – CommunicationSTR – StressCHG – Change
Organizational Survey for Treatment Staff (ORC-TS)
10
15
20
25
30
35
40
45
50
SN PN TN PC OFF STF TRN EQP INT SUP GRO EFF INF ADP SAT MIS COH AUT COM STR CHG
Needs/Pressures
Organizational Survey for Treatment Staff (ORC-TS)
Resources Staff Attributes Organizational Climate
Scale Scores (10-Low; 50-High)
Strategies for Organizational Change?
© 2010
If LOW, then what can be done -- and how??
© 2010
Diagnostic tools for Organizational Change(Readiness and Capacity)
Organizational Assessment
Battery
Structure & Ops(SSO)
Needs/Pressure(ORC)
Resources(ORC)
Staff Attributes(ORC)
Climate(ORC) Identify
Institutional Barriers
Identify Training Needs
Improve Organizational Functioning
Implementing Evidence-based Practices
AdequateRetentionAdequateRetention
Change: Behavioral
Change: Behavioral
Change: Psycho-Social
Change: Psycho-Social
ProgramParticipation
ProgramParticipation
TherapeuticRelationship
TherapeuticRelationship
TCU Treatment Process Model(Stage-based assessments & interventions)
Trea
tmen
t P
lan
nin
g &
Del
iver
y S
yste
m
Based on Simpson, 2004; Simpson & Joe, 2004 (JSAT)
Program• Needs/motives• Resources• Staff skills• Climate
Drug Use & Risks
Screening
Follow-upOutcomes• Drug use• Crime• Social
Follow-upOutcomes• Drug use• Crime• Social
BehavioralInterventions
Social SkillsTraining
ReadinessInterventions
CognitiveInterventions
Recovery SkillsTraining
Detox/Meds
Motivation& Induction
RisksReduction
SupportNetworks
Trt/CarePlanning
CM/RewardStrategies
CognitiveFocusing
ThinkingPatterns
BetterComm
LivingSkills
ProgressMonitoring
TransitionPlanning
TreatmentReadiness:• Needs• Severity• Motivation
TreatmentReadiness:• Needs• Severity• Motivation
© 2010
Other Treatments
or Support
Networks
Other Treatments
or Support
Networks
Check List for System Effectiveness
1. Are current assessments reliable measures of client needs and stages of change?
2. Do current interventions show measureable evidence of effectiveness?
3. Are these treatment components clearly interconnected and understood by staff?
4. Has “better” care planning improved engagement and retention in treatment?
5. Are there organizational/staff barriers that affect your operational/performance levels?
© 2010
TCU Treatment Process Model(Stage-based assessments & interventions)
Trea
tmen
t P
lan
nin
g &
Del
iver
y S
yste
m
Based on Simpson, 2004; Simpson & Joe, 2004 (JSAT)
Program• Needs/motives• Resources• Staff skills• Climate
Drug Use & Risks
Screening
Other Treatments
or Support
Networks
Other Treatments
or Support
Networks
Follow-upOutcomes• Drug use• Crime• Social
Follow-upOutcomes• Drug use• Crime• Social
Engagement•
Participatio
n•
Therapeutic
Relationship
RetentionThreshold
ChangeChanges in --• Thinking• Acting
BehavioralInterventions
Social SkillsTraining
ReadinessInterventions
CognitiveInterventions
Recovery SkillsTraining
Detox/Meds
Motivation& Induction
RisksReduction
SupportNetworks
Trt/CarePlanning
CM/RewardStrategies
CognitiveFocusing
ThinkingPatterns
BetterComm
LivingSkills
ProgressMonitoring
TransitionPlanning
TreatmentReadiness:• Needs• Severity• Motivation
TreatmentReadiness:• Needs• Severity• Motivation
© 2010
And finally…
• Calibrate needs & services for clients (care plans)
Triage clients into intensity levels (especially CJ)
• Deliver effective treatment process Assessments & Interventions that work & inter-connect
• Translate local/national policy statements SAMHSA/ONDCP plans & “new” emphasis on Recovery??
• Attend to organizational climate/functioning
© 2010
“How do we keep doing more with less and also show favorable evidence for outcomes”?
SelectedPresentations
IBR HOME PAGE
IBRA National Research Center
for addiction treatment studies in community and correctional
settings(over 600 free resource files
available)
DATOSDATOS
ProgramProgramProgram
StaffStaffStaff
ResourcesResourcesResources
ClimateClimateClimate
PatientPatientPatient
SeveritySeveritySeverity
ReadinessReadinessReadiness
SufficientRetentionSufficientSufficientRetentionRetention
Early Early EngagementEngagement
Early Early RecoveryRecovery
PosttreatmentPosttreatment
DrugUse
DrugDrugUseUse
CrimeCrimeCrime
SocialRelations
SocialSocialRelationsRelations
ProgramParticipation
ProgramProgramParticipationParticipation
TherapeuticRelationship
TherapeuticTherapeuticRelationshipRelationship
BehavioralChange
BehavioralBehavioralChangeChange
Psycho-SocialChange
PsychoPsycho--SocialSocialChangeChange
EvidenceEvidence--Based Treatment ModelBased Treatment Model
CognitiveCognitiveStrategiesStrategies
BehavioralBehavioralStrategiesStrategies
Social SkillsSocial SkillsTrainingTraining
Family &Family &FriendsFriends
SupportiveNetworks
SupportiveSupportiveNetworksNetworks
Personal Health ServicesPersonal Health Services
Social Support ServicesSocial Support Services
Simpson, 2001 (Addiction)
ProgramProgramInterventionsInterventions
ReadinessReadinessTrainingTraining
SUMMARY
TCU Mapping-Enhanced
Counseling
TreatmentProcess
Counseling Manuals
Corrections-Based
Treatment
NationalEvaluations
OrganizationalReadiness
AssessmentFact Sheets(with norms)
www.ibr.tcu.edu
• Overview of Adaptive Treatment
System & Conceptual Models
See Guide for New Visitors
• Guide to Intervention Manuals
• Guide to Assessment Forms
• Project Updates & Summaries
• Newsletters, Presentations, and Publications (Abstracts)
EVIDENCE
MANUALSFORMSEVIDENCE ABOUT IBR-TCUSTAFFPUBLICATIONSPRESENTATIONS PROJECTSNEWSLETTERS
OTHER LINKSWHAT’S NEW
SITE GUIDES:
© 2010