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Transforming a residential substancedependence program: experience fromthe National Rehabilitation Centre,United Arab EmiratesHesham Elarabia, Naseeba Alozaibia, Mansour Shawkya, ShamilWanigaratnea, Susan Salasb, Fatima Al Hamediac, Buthaina AlMaskarid, Sarah Al Marzooqic, Alyazia Al Khajae & Hamad AlGhaferiaa National Rehabilitation Center, Abu Dhabi, United Arab Emiratesb Susan Salas Consulting, UKc Institute of Psychiatry, Kings College, London, UKd Sheikh Khalifa Medical City- SEHA, Abu Dhabi, United ArabEmiratese Independent Psychologist, Abu Dhabi, United Arab EmiratesPublished online: 16 Jul 2014.

To cite this article: Hesham Elarabi, Naseeba Alozaibi, Mansour Shawky, Shamil Wanigaratne,Susan Salas, Fatima Al Hamedi, Buthaina Al Maskari, Sarah Al Marzooqi, Alyazia Al Khaja & HamadAl Ghaferi (2014) Transforming a residential substance dependence program: experience fromthe National Rehabilitation Centre, United Arab Emirates, Mental Health and Substance Use, 7:4,353-362, DOI: 10.1080/17523281.2014.939218

To link to this article: http://dx.doi.org/10.1080/17523281.2014.939218

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Transforming a residential substance dependence program: experiencefrom the National Rehabilitation Centre, United Arab Emirates

Hesham Elarabia*, Naseeba Alozaibia, Mansour Shawkya, Shamil Wanigaratnea,Susan Salasb, Fatima Al Hamedia,c, Buthaina Al Maskarid, Sarah Al Marzooqic,

Alyazia Al Khajae and Hamad Al Ghaferia

aNational Rehabilitation Center, Abu Dhabi, United Arab Emirates; bSusan Salas Consulting, UK;cInstitute of Psychiatry, Kings College, London, UK; dSheikh Khalifa Medical City- SEHA, AbuDhabi, United Arab Emirates; eIndependent Psychologist, Abu Dhabi, United Arab Emirates

(Accepted 22 June 2014)

This article describes the experience of transforming a residential substance dependencetreatment program from an extended non-structured program to a structured,differentiated short-term residential treatment which allows for treatmentpersonalization. Carried at the National Rehabilitation Centre, Abu Dhabi, UnitedArab Emirates, and commissioned by its management, the transformation aimed toaddress extended length of stay, long waiting lists, service expansion requirement,and diversity in demand for treatment. Transforming the residential program wouldoptimize efficiency as it is the most common and resourceful phase of substancedependence treatment regionally, hence the significance of this effort. Thetransformation process extended from April 2009 to April 20l3 over two phases: (a)program development and (b) implementation. Gaps in human resource capacity, andthe absence of monitoring and evaluation systems were identified as major challengesin transformation. Six recommendations were generated including furtherdifferentiation of the residential program, one of the components of the continuum ofcare, to phases with measurable outcomes. Adoption of evidence-based interventionsshould ensure not only selection but extend to cover quality of delivery andintegration of interventions. Engagement of staff delivering these programs throughadequate capacity building and regular program assessments becomes indispensable.In order to achieve proper program transformation, efficient leadership dedicated tothe process is imperative.

Keywords: comorbidity; inpatient treatment; assessment; residential treatment;treatment outcome; service provision

Introduction

The Bio-Psycho-Socio-Spiritual model of substance dependence informs treatment deliverythrough a continuum of care, (McLellan, Lewis, O’Brien, & Kleber, 2000) best visualizedas stepped care of intensive treatment, linked to maintenance care tailored to patient needsguided by periodic assessments (McKay, 2006). The American Society of AddictionMedicine (2001) associated effective substance dependence treatment and care programs

© 2014 Taylor & Francis

*Corresponding author. Email: hisham.alarabi@nrc.ae

Mental Health and Substance Use, 2014Vol. 7, No. 4, 353–362, http://dx.doi.org/10.1080/17523281.2014.939218

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with internal factors such as aims and objectives, treatment model or philosophy, availableresources and organizational factors; and external factors such as national policies, servicesystems, clientele profile, and the cultural context where treatment takes place. Thus, tooptimize effectiveness, evidence-based interventions should be adapted to populationneeds; programs lacking such adaptability often observe wide gaps between the interven-tion and clinical care (Lash, Timko, Curran, & McKay, 2011).

Internal factors variably impact quality and efficiency of service delivery and literatureindicates the importance of organizational climate, availability of skilled staff, and their atti-tudes in optimizing treatment outcomes (Dansereau & Simpson, 2006). Staff training andgood patient assessment systems in particular were found to have stronger positive influ-ence on quality and efficiency of service delivery compared to organizational factorssuch as organizational size (Gotham, Claus, Selig, & Homer, 2010).

Developing culturally sensitive and practical guidelines for substance dependence treat-ment programs is particularly difficult. However, specifics of establishing drug treatmentsystems have been successfully outlined in international guidelines (UNODC, 2003).These guidelines do not focus on a specific level of care and provide general principleslisting evidence-based interventions to be used across the continuum of care. However,the rationale and need for residential programs are identified as providing multiple treat-ments for complex patient needs (NICE, 2013; UNODC, 2003).

Based in Abu Dhabi, UAE, the National Rehabilitation Centre (NRC) was establishedin 2002 as a substance use response center. In 2010, a residential program consisting of 26beds distributed over detoxification and rehabilitation units, a 15-bed long-term stay thera-peutic community, and an outpatient clinic composed the NRC operations. The NRC hasobserved an increasing demand for residential treatment, the commonly available levelof substance dependence care in the UAE.

In 2010, one-third of the patient population had alcohol use disorders, one-third had poly-substance use including alcohol use, and one-third had mixed cannabis and illicit opioid use.However, the aggregate substance use landscape has changed and currently almost half (51%)of the patients presenting to NRC are poly-substance users, 24% alcohol users, 10% opioidsusers, 6% cannabis users, and 9% other drugs users. Themedian patient age band has droppedfrom 30–40 years to 20–30, with a marked increase of adolescents under the age of 20 yearsfrom 3% to 10%. The service observed extended length of stay averaging at 93–127 days,almost three-fold the length of stay described for short-term residential programs (Feidler,Screen, Greenfiled, & Fountain, 2001) and an extended patient waiting list. Consequently,external consultants invited in 2009 for service assessment evaluated the residentialprogram (Table 1) as non-therapeutic and non-structured, which did not reflect an integratedcontinuumof care and there existed a need to transform the residential program (ISAM,2009).In this connection, restructuring the residential program became a top priority for the NRC’smanagement and a multidisciplinary task force was assigned to take this initiative forward.

Regionally, substance use treatment settings were described in the Kingdom of SaudiArabia, which included a total of 11 treatment components, namely pharmacological; com-munity meetings; group therapy; individual therapy; educational activity; recovery groups;family therapy; religious and spiritual groups; activity therapy; biofeedback; and self-help(Abdel-Mawgoud, Fateem, & Al-Sharif, 1995). The paper further lists three levels of care:assessment and detoxification, short-term rehabilitation, and continued care.

This article describes the experience transforming a residential treatment and careprogram at the NRC from April 2009 to April 2013. It highlights the importance of devel-oping local human capacities and program adaptation to the local context, and reinforces theneed for conducting outcome measurement.

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The transformation process

A task force comprising a senior manager, psychiatrists, psychologists, and physicians (n = 7)was assigned by the NRC management to carry out the transformation that progressed overtwo phases, program development and program implementation. These phases are further dif-ferentiated into additional steps described below.

Phase I: program development

Step one: scoping therapeutic interventions

Extensive literature review was performed using Psych-INFO and OVID Medline database. Key search words used were evidence-based practice/medicine, addiction/substancedependence program and program development, and addiction and substance dependence.Over 160 English peer-reviewed abstracts and 16 articles on treatment for addiction anddual diagnosis services were retrieved, which included the treatment guidelines from theUnited Nations Office on Drug and Crime (UNODC, 2003) and the National Institute forHealth Care Excellence, UK (NICE, 2013). The reviewed literature revealed that certaininterventions are studied and practiced in greater depth than others (Fenny, 2000).Despite the difficultly in providing a conclusive guide on selecting evidence-based inter-ventions, a review undertaken by Miller, Zweben, and Johnson (2005) listed 29 differentinterventions of which cognitive behavioral therapy (CBT), relapse prevention, communityreinforcement approach social skills training, motivational interviewing, and maritaltherapy (family therapy) were rated among interventions with strongest evidence. Insummary, interventions could be classified into four major categories: motivational inter-viewing and motivational enhancement, CBT, family therapy, pharmacotherapy andalternative auxiliary interventions. Nevertheless, literature revealed that adoption of evi-dence-based treatments may not be enough to optimize treatment outcomes, and thus anintegrated program delivery model is encouraged (Lash et al., 2011). Consequently,

Table 1. Non-structured program requiring transformation.

Time/day Sunday Monday Tuesday Wednesday Thursday Friday Saturday

07:00 Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast07:30–09:30 Exercise Family

visitsFamily visits

10:00–11:00 Grouptherapy

Healtheducation

Grouptherapy

Matrixgroup

Grouptherapy

Familyvisits

Family visits

11:00–12:00 Recoverygroups

Computerclasses

Computerclasses

Computerclasses

Individualtherapy

Familyvisits

Family visits

12:00–13:00 Familyvisits

Family visits

13:00–14:00 Individualtherapy

Nutritionprogram

Individualtherapy

Individualtherapy

Nutritionprogram

Familyvisits

Family visits

14:00–15:00 Familyvisits

Family visits

15:00–17:00 Lunch andrest

Lunch andrest

Lunch andrest

Lunch andrest

Lunch andrest

Familyvisits

Family visits

18:00–20:00 Artactivity

Languageclasses

Languageclasses

Languageclasses

Recreation Familyvisits

Family visits

20:00–21:00 Religioustutoring

Languageclasses

Languageclasses

Languageclasses

Recreation Familyvisits

Interpersonalgroups

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therapeutic alliance and competencies of service providers were found to be significant inoptimizing treatment outcomes (Miller et al., 2005). Furthermore, collaborative workbetween clinicians and clients contributes to the effectiveness of treatment (Fenny, 2000).

Step two: program benchmarking

In order to define the optimal program duration, benchmarking with international programswas performed. Programs with comparable mandates to that of the NRC were selectedusing a set of domains:

(i) Personalization of treatment,(ii) patient involvement in treatment planning,(iii) structured programs with procedures, evaluation tools,(iv) level of care designed as a continuum of care,(v) evidence-based interventions in the program,(vi) program is performance based,(vii) program is outcome based,(viii) treatment team is a homogenous multidisciplinary team,(ix) program is flexible and comprehensive to cater to different patient needs evalu-

ated on five-point scales (strongly agree = 5 and strongly disagree = 1).

Only those programs receiving at least three points on any single question were selected forbenchmarking, e.g. Henry Ford Maple Grove Centre, which endorsed a continuum of careapproach and comprehensive program that can be tailored to diverse patient needs.

The benchmarking considered the context of service mandate, service capacity, and themacro health-care system. Consequently, the optimal duration of the program was set at sixweeks, differentiated to three continuous phases, starting with acute management, assess-ment, and motivation, moving toward treatment induction early recovery and then transi-tioning to outpatient and after care. Nevertheless, the program duration remained to beadjusted to individual needs identified during the assessment phase.

Step three: program mapping

Taking forward results from step one, and using the following overarching principles, non-clinical programs would be delivered outside the working hours of the therapists. Interven-tions wherever possible would be subjected to evaluation and linked to outcomes, inclusionof CBT, family therapy, auxiliary interventions, and assigning a case manager or a keyworker. The program mapping was done to generate a therapeutic program extendingover six weeks described below.

After medical stabilization and detoxification, “Week One” commences with compre-hensive multidisciplinary assessment (medical, psychiatric, psychological, occupational,and nutritional assessments). Assessment feedback scheduled in “Week Two” providesthe opportunity for patient motivation and engagement in treatment planning and sets thestage for individualized treatment.

During “Week Two” medication management, relaxation, motivational enhancementsessions are scheduled and behavioral modification adapted to the local cultural contextis introduced. For example, performing the five daily congressional prayers at fixedtimings encourages patients to structure their day around the prayer timings. In addition

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to its spiritual benefits, this application promotes regular “mindfulness” and represents howcultural elements adapt therapeutic principles.

Weeks “Three to Six” (Table 2) reflect treatment induction and early recovery phaseinformed by the assessments from the assessment phase. This phase anchors intensive treat-ment marked by a comprehensive CBT menu with increasing intensity from “Week Three”onwards, which is predominantly marked by a behavioral component. The CBT menuincludes interventions for co-occurring disorders including anxiety, depression, andbipolar, relapse prevention, and social skills training (life skills). Self-help together withmindfulness-based relapse prevention is also introduced at “Week Four” with increasingfrequency toward Week six. Similarly, family therapy and family work, motivationalenhancement, and auxiliary interventions commence at “Week Four”. In preparation fordischarge to the next level of care, the treatment plan is reviewed with the patient who iswalked through the ambulatory care program. Extensive family work and social workare done starting “Week Five” and the first outpatient appointment is scheduled withoutlag periods to minimize risk of relapse at Week Six (Feidler et al., 2001).

Phase II: program implementation

A roadmap to implement the mapped program clinically and ensure its sustainability wasdeveloped in this step. Program implementation was largely seen as the most challengingstep in system transformation.

Step one: identifying needs for implementation

In anticipation of potential resistance, (Comprehensive Framework for ImplementationResearch (CFIR): Damschroder et al., 2009) the Organizational Readiness to ChangeStaff Version by the Texas Christian University (ORC-TCU), Simpson, 2002) was com-pleted by different clinicians, including the task force, with the intention to identify, prior-itize, and proactively address the anticipated resistance. The ORC-TCU providesinformation on four domains; motivation for change, resources, staff attributes, and organ-izational climate. Each domain is built of several parameters and each parameter has a set ofitems scored on a five-point likert scale, from 1 representing strongly disagree to 5 asstrongly agree. These Domains are interrelated and should be read accordingly. Forinstance, under the domain “Motivation for Change”, “Agency Needs” and “Pressure toChange” parameters identify drivers for change, yet no change can be achieved withoutadequate resources such as skilled staff and appropriate organizational climate to fosterthis change. The tool was completed by staff from psychiatry, psychology, social work,health education, and two nurses including the nursing manager (n = 14). Very limitednumber of the nursing staff completed the form as the nursing department was observingsignificant and particular challenges. Roles and responsibilities of the nursing departmentwere not well structured and framed at commencement of the transformation process andnursing contribution to the treatment and care process was not recognized or realized(ISAM, 2009).

Scoring and interpretation using the TCU-ORC guide generated scores in the range of10–50 (Table 3). A score of 30 is set as a cut-off for the degree of agreement and disagree-ment with the need to change. For instance, scores below 30 represented the highest need tochange and develop. All four domains – motivation to change, resources, staff attributes,and organizational climates – were scored below 30. The “motivation for change”domain gathered the lowest score (20.8), indicating a higher need for change. In contrast,

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Table 2. Mapped residential program (Week Three).

Time/day Sunday Monday Tuesday Wednesday Thursday Friday Saturday

07:15–7:45 Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast08:00–9:00 Medication

managementSocial work

assessmentfeedback

Medicationmanagement

Medicationmanagement

Medicationmanagement

Medicationmanagement

Medicationmanagement

09:00–10:00 Meditation Meditation Meditation Meditation Meditation Meditation Meditation10:00–11:00 CBT depression CBT anxiety Motivation

enhancementPsychoeducation

setting goalsEmotional

processingFamily visit Family visit

11:00–12:00 Individual therapy Individual therapy Individual therapy Individual therapy Individual therapy Family visit Family visit12:00–13:00 Story telling Motivational

enhancementOccupational

therapyRelapse prevention Interpersonal group Friday prayer Family visit

13:00–14:00 Medical clinic Health education CBT anxiety Behavioral group Health education Religious support NutritionDohur prayer Dohur prayer Dohur prayer Dohur prayer Dohur prayer Dohur prayer Dohur prayer14:00–16:00 Lunch and rest Lunch and rest Lunch and rest Lunch and rest Lunch and rest Lunch and rest Lunch and restAsr prayer Asr prayer Asr prayer Asr prayer Asr prayer Asr Ppayer Asr prayer Asr prayer16:30–18:00 Exercise Exercise Exercise Exercise Exercise Exercise Exercise18:00–19:00 Maghreb prayer and

religious tutoringMaghreb prayer and

religious tutoringMaghreb prayer and

religious tutoringMaghreb prayer and

religious tutoringMaghreb prayer and

religious tutoringMaghreb prayer and

religious tutoringNon-

structuredgroupactivity

19:00–20:00 Vocational training Vocational training Vocational training Vocational training Vocational training Group recreation Vocational training20:00–21:00 Dinner Dinner Dinner Dinner Dinner Dinner Dinner21:00–22:00 Reflection group Reflection group Reflection group Reflection group Reflection group Reflection group Reflection group22:00–22:30 Meditation Meditation Meditation Meditation Meditation Meditation Meditation23:30 Bed time Bed time Bed time Bed time Bed time Bed time Bed time

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the “organizational climate” domain scored the highest score below 30 (26.9). All otherdomains scored below the 25th quartile. Under the “motivation for change” domain, theneed for program development was perceived as the most critical parameter as it gatheredthe lowest score (14.8). Moreover, “developing effective group sessions” and “raisingoverall quality of counselling” followed by the need to “assess client performance” itemswere rated to carry the highest need to change under the program development parameter.These results informed how to prioritize barriers for implementing the mapped program inPhase One, and identified human resources capacity building including clinical leadershipas a major barrier to the transformation.

Step two: developing the implementation strategy

Needs for realizing this mapped program were outlined using an analysis matrix developedand completed by the task force. Identifying needs for each intervention introduced wasdone on five main domains: Training (skills and competencies), Human Resources,Materials, Administrative needs (policies and procedures), and logistical needs like phys-ical space and equipment (Table 4). New introductions that required low intensity training,minimal or no additional human resources or logistics were first to be introduced accordingto the implementation strategy.

Building on outcomes of steps one and two of the implementation phase, the task forcedeveloped a strategy for implementation. The highlights of this are to engage clinical staffthrough longitudinal training on new therapeutic interventions, to conduct performance andoutcome evaluation, and introduce interventions requiring low-intensity training withoutadditional human resources or logistics during the first 12–18 months. Meanwhile, estab-lishing clinical leaderships with ownership of the transformation project and deliveringrelapse prevention training was done. At large, introductions of new assessments and inter-ventions were done incrementally.

Introduction and establishment of the next level of care was carried over the next 12–18months. In the interim, program evaluations and assessments were performed to engagestaff and reinforce their ownership of the program. The transformation process was

Table 3. Results from TCU-ORC.

TCU-ORC domain Score TCU-ORC domain Score

Staff atributes 23.8 Resources 26.2Growth 22.3 Office 27.9Efficacy 21.3 Staffing 27.8Influence 26.9 Training 26.7Adaptability 20.8 Equipment 24.5Satisfaction 27.5 Internet 23.8Organizational climate 26.8 Motivation for change 20.8Mission 28 Program needs 14.8Cohesion 30.6 Training needs 18.6Autonomy 31 Pressure for change 29.3Communication 27.7Stress 22.7Change 26.7Leadership 21.7Influence 26.9

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considered complete when the program components were fully functional and the durationdropped efficiently to six weeks.

Discussion

Despite that this article is not intended to evaluate transformation outcomes, it is worthwhileto highlight several milestones achieved further to this transformation. Organizationally, theprogram enjoyed new clinical leaderships with regular program reviews and evaluations.Extensive training and professional development programs were carried out. Operationally,service waiting lists decreased by 80%, length of inpatient stay was reduced by 50% (90–120 days Vs. 45–60 days), while number of patients admitted to the service increased four-fold. Furthermore, the service was able to address changes in substance use landscape, anddevelop focused adolescent and female treatment programs without significant increase inthe required human resources. Additionally, discharge against medical advice has droppedby 50%, increasing patient retention rates. In this context, the transformation process is ren-dered successful, meeting all the pre-set objectives.

With no standard reference to guide transformation of substance dependence residentialprogram, this effort utilized international literature and experience of the task force. Despitedescribing a single level of care, this article differentiates the residential program to:

Table 4. Gap analysis matrix.

NewIntroductions

Required needs

TrainingHumanresources

Materialresources

Policy andprocedures

Physical andlogistics

Assessment tools Required for newtools, e.g.addictionseverity index

Available Required Not required Available

Meditationrelaxationgroups

Low-intensitytraining fornursing/socialworkers

Available Notrequired

Required Dedicatedspace notrequired

Emotionalprocessinggroups

Medium-intensitytraining andsupervision

Available Required Not required Dedicatedspace notrequired

Occupationaltherapy

Capacity buildingtraining

Required Tools Required Dedicatedspacerequired

Reflectiongroups

Low-intensitytraining

Nursesavailable

Notrequired

Required Not required

Relapsepreventiongroups

High-intensitytraining

Multi-disciplinaryteam DT

Notrequired

Require manualdevelopment

No dedicatedspace

Family therapy High-intensitytraining

Available Required Requiredmanual

No dedicatedspace

Family work andeducation

Low intensity Available Available Available Available

Psycho-education

Low intensity Available Required Available Available

Religioustutoring

Medium intensity Available Required Required Available

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(i) acute, assessment, and motivation,(ii) treatment induction and early recovery,(iii) transition to next level of care.

Such differentiation allows defining objectives and optimizing efficiency of each phase.Implementation progressed according to available resources and preparedness as guided

by the Gap analysis Matrix used in Phase II. This matrix was found comparable to the(CFIR: Damschroder et al., 2009) and covered two of the five CFIR domains, i.e. “interven-tion characteristics” and “characteristics of the individuals involved with implementation”.In the same connection, the ORC-TCU tool applied in step one of Phase II (IdentifyingImplementation Needs) further identified and prioritized areas of readiness or resistanceto implementation. “Program Needs” was identified as the domain with the highest needfor development within which the two items “Developing more effective group sessions”and “raising overall quality of counselling” related to human competencies were ratedexceptionally low, i.e. requiring the highest need to change. Similar to findings fromProject MATCH, which revealed the significance of how treatment is delivered comparedto the type of intervention (Project Match Research Group, 1997), using the ORC-TCUidentified a need for developing quality of interventions in optimizing treatment outcomes.This is further supported by scores from the “staff attributes” parameter (< 30), whichsuggested a need for development.

In the same connection, staff observed high stress levels, and had low perception of lea-dership, and limited confidence that decision-making was done on a shared basis. Similarly,the “Cohesion” parameter under the “organization climate” domain continued to score low(30.6). Results from staff-related parameters suggested a need for immediate attention tohuman resources. These findings are further reinforced by results from external audits,necessitating the development of quality of treatment (ISAM, 2009). On the other hand,staff who completed the ORC-TCU rated the main pressure to change as external and emer-ging primarily from funding and oversight agencies rather than internal factors, e.g. staffand clients, which could be one reason for resistance to change.

The main limitation of this transformation process was that ORC-TCU results guidingthe implementation were completed by members from all disciplines with limited represen-tation from nursing (n = 2). The primary reason was poor definition of nursing roles andresponsibilities with limited contribution to treatment and care delivery (ISAM, 2009).Thus, the task force together with the nursing manager felt that wide involvement ofnursing in this process would skew the results, and involving nursing in the implementationwas not feasible at the time. It is worth noting that the nursing department was undergoingmajor assessment and reform (Elarabi, Hajal, Salas, & Wanigaratne, 2013).

In conclusion, several recommendations can be drawn for comparable organizationswith similar challenges or for those setting up residential programs. The recommendationsre-produced principles defined by international guidelines enhanced by this experience:

(i) Program design should stem from service mandate.(ii) Residential programs should be differentiated to phases with measurable

objectives.(iii) Selection of interventions should not be limited to evidence-based interventions

only and auxiliary treatments of cultural acceptance should be considered.(iv) Program developers should consider how selected evidence-based interventions

are delivered and integrated.

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(v) Engaging staff responsible for delivering these programs through adequatecapacity building and active participation in program development is mandatory.This should be considered in light of an efficient leadership dedicated to the trans-formation process.

(vi) Implementation of new treatment models should progress incrementally coupledwith regular assessments.

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