Michael S. Levy, Ph.D. CAB Health & Recovery Services, Inc. Peabody, MA

1. Evidence-based Practices (EBPs) in Community Treatment Programs: EBPs are just one piece of the pieAmerican Psychological Association ConferenceSan Francisco 2007 Michael S. Levy, Ph.D. CAB Health & Recovery Services, Inc. Peabody, MA

2. Key Factors Relevant to Client Change Processes Lambert, M.J. (1992). Implications of Outcome Research for Psychotherapy Integration. In J.C. Norcross & M. R. Goldstein (Eds.), Handbook of Psychotherapy Integration (pp. 94-129). New York: Basic Books.

3. “Psychotherapy manuals are helpful for training and research. In particular, they enhance the internal validity of comparative outcome studies, facilitate treatment integrity, ensure the possibility of replication, and provide a systematic way of training and supervising therapists. At the same time, manuals are also associated with some untold negative effects. There is no conclusive evidence that manuals improve treatment outcomes or that they should be required in practice.” (Norcross, Beutler, & Levant, Evidence-based Practice in Mental Health, 2006)

4. “Manualizing psychological interventions as if they were independent of those administering and receiving them does not reflect what is known about psychotherapy outcome.” (Duncan & Miller, 2006).

5. In looking at individual drug counseling (IDC) in NIDA’s Collaborative Cocaine Treatment Study, it was found that in cases when the alliance was strong, counselor adherence did not much matter; those patients typically improved. However, for cases in which the alliance was weak, adherence did matter. Those patients improved more when their counselors adhered moderately to IDC principles than when the counselors were either minimally or highly adherent (Barber, et al., Psychotherapy Research, 16, 229-240, 2006).

6. “It makes good sense to give priority to EBTs, particularly within this era of fiscal austerity. We owe it to our clients to provide the best possible treatment within available resources.” (Miller, Zweben, and Johnson, JSAT, 29, 267-276, 2005).

7. “…in community-based settings there is often not enough money to recruit and maintain a workforce qualified to provide evidence-based treatments” (Expert Panel on Juvenile Justice and Adolescent Substance Abuse Treatment, April 2007).

8. NIDA’s Principles of Drug Addiction Treatment: • No single treatment is appropriate for all individuals. • Treatment needs to be readily available. • Effective treatment attends to multiple needs of the individual, not just his or her drug use. • An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person’s changing needs. • Remaining in treatment for an adequate period of time is critical for treatment effectiveness.

9. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. • Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. • Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. • Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use.

10. Treatment does not need to be voluntary to be effective. • Possible drug use during treatment must be monitored continuously. • Treatment programs should provide assessment for HIV/AIDS, Hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. • Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.

11. Network for the Improvement of Addiction Treatment (NIATx ) Focuses on: • Decreasing time to obtain treatment. • Increasing admissions. • Decreasing no show rates. • Increasing treatment retention. • Uses rapid cycle plan-do-study-act projects,as opposed to evidence-based practices.

12. Most all EBPs focus on the outpatient realm, so what about residential treatment which can offer 90 -250 different groups during a treatment experience, not to mention that group size can vary from 15 to 30 to 40 and even more. • And what about a detoxification program with a length of stay of 4-6 days?

13. List of OMHAS Approved Evidence-Based Practices • CYT: Family Support Network (FSN) for Adolescent Cannibis Users • CYT: Multidimensional Family Therapy for Adolescent Cannabis Users (MDFT) • Dialectical Behavioral Therapy (DBT) Approaches • DBT adapted for adolescents • DBT for Substance Abuse (DBT-S) • Supported Employment • Co-occurring Disorders: Integrated Dual Diagnosis Treatment (IDDT) • Illness Management and Recovery • Family Psychoeducation • Assertive Community Treatment (ACT) • Medication Management Approaches in Psychiatry (MedMAP) • Stimulant Treatment of ADHD (methylphenidate, dextroamphetamine, mixed salts emphetamine, pemoline)

14. List of OMHAS Approved Evidence-Based Practices • Multisystemic Therapy MST) • Cognitive Behavior Treatment for Childhood Anxiety Disorders • Trauma Focused Cognitive Behavioral Therapy • Parent Management Training • Multi-Dimension Treatment Foster Care (MTFC) • Brief Strategic Family Therapy • Wraparound (a treatment planning process model, not a treatment model • Functional Family Therapy • Seeking Safety: “a present-focused therapy to help people attain safety from trauma/PTSD and substance abuse” • Communities that Care • LifeSkills Training • Incredible Years

15. List of OMHAS Approved Evidence-Based Practices • ASAM Patient Placement Criteria 2nd Edition-Revised • The Matrix Model: Outpatient Stimulant Treatment • Methadone Maintenance • Motivational Enhancement Therapy • Twelve-Step Facilitation Therapy • Cognitive Behavioral Therapy • Motivational Interviewing • Motivational Enhancement Therapy/Cognitive Behavioral Therapy (MET/CBT) for Adolescent Cannibis Users: 5 Sessions • CYT: Motivational Enhancement Therapy and Cognitive Behavioral Therapy Supplement: 7 Sessions of Cognitive Behavioral Therapy for Adolescent Users • CYT: The Adolescent Community Reinforcement Approach for Adolescent Cannibis Users (ACRA)

16. List of OMHAS Approved Evidence-Based Practices • Motivational Interviewing • Seeking Safety

17. NREPP’s Evidence-based Practices • Behavioral Couples Therapy for Alcoholism and Drug Abuse • Border Binge-Drinking Reduction Program • Brief Marijuana Dependence Counseling • Challenging College Alcohol Abuse • Clinician-Based Cognitive Psychoeducational Intervention for Families • Cognitive Behavioral Social Skills Training • Cognitive Behavioral Therapy for Adolescent Depression • Cognitive Behavioral Therapy for Late-Life Depression • Coping Cat • Critical Time Intervention • DARE to be You • Dialectical Behavior Therapy • Family Matters • Functional Adaptation Skills Training (FAST) • Lions Quest Skills for Adolescents

18. NREPP’s Evidence-based Practices • Matrix Model • Multisystemic Therapy (MST) for Juvenile Offenders • Network Therapy • New Beginnings Program • Parenting Through Change • Prevention and Relationship Enhancement Program (PREP) • Primary Project • Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) • Project ALERT • Project EX • Project Northland • Project Towards No Drug Abuse • Responding in Peaceful and Positive Ways (RiPP) • Safe Date

19. NREPP’s Evidence-based Practices • Second Step • Seeking Safety • SMARTteam • SOS Signs of Suicide • Success in Stages: Build Respect, Stop Bullying • Trauma Recovery and Empowerment Model (TREM) • United States air Force Suicide Prevention Program

20. NREPP’s Evidence-based Practices • Motivational Interviewing • Seeking Safety

21. A sample of specific treatments and evidence-based practices for the treatment of addiction. • Acceptance and Commitment Therapy, Acupuncture, Affective Contra-Attribution Therapy, Assertive Community Treatment, Aversive Counter-conditioning, BAC Discrimination Training, Behavior Contracting, Behavioral Marital Therapy, Behavioral Self-Control Training, Bibliotherapy, Brief Intervention, Brief Strategic Family Therapy, Biofeedback, Client-Centered Therapy, Cognitive Therapy, Community Reinforcement Approach, Contingency Management, Covert Sensitization, Cue Exposure, Dialectical Behavior Therapy, Existential Therapy, Functional Analysis, Functional Family Therapy, Group Psychotherapy, Guided Self-Change, Hypnosis, Matrix Model, Medical Management, Mindfulness, Minnesota Model, Moderation Management, Motivational Enhancement Therapy, Motivational Interviewing, Multidimensional Family Therapy, Multisystemic Therapy, Problem Solving, Psychodynamic Psychotherapy, Psychoeducation, Rational Emotive Therapy, Rational Recovery, Recreational Therapy, Relapse Prevention Relaxation Training, Secular Organization for Sobriety, Self-Monitoring, Social Skills Training, Stress Management, Solution-Focused Therapy, Supportive-Expressive Psychotherapy, Systematic Desensitization, Therapeutic Community, Transcendental Meditation, Twelve-Step Facilitation Therapy, Women for Sobriety. (From Miller, W., 2006, Presentation at 2006 Blending Conference, Seattle, WA)

22. There must be some commonalities among EBPs that attempt to treat clients who suffer from addictive disorders. • If this is true, how much energy should be placed on training regarding specific EBPs or instead, could energy be better spent on other things?

23. EBPs that are Implemented • Motivational interviewing • Methadone • Buprenorphine • Naltrexone, Acamprosate, Vivitrol (Soon) • Contingency Management • Matrix Model • Adolescent Community Reinforcement Approach – Assertive Continuing Care (ACRA/ACC) • Harm Reduction • Seeking Safety

24. Train ALL staff in overriding principles of quality treatment of addiction. • Address motivation and reinforcing factors of using drugs, and help clients to develop non-drug reinforcing activities. • Don’t be confrontational and meet clients where they are at. • Teach specific coping skills and ways to avoid a return to drug use. • Attend to the client’s social environment. • Think about psychopharmacological intervention. • Your relationship to the client is critical and extremely important. • You must attend to the multiple treatment needs that clients have.

25. Client Satisfaction • An extreme focus on the importance of client satisfaction and at all times, treating clients with dignity and respect. This includes nursing staff, clinical staff, and milieu staff, as well as non-clinical staff. • Power and powerlessness trainings. • Client satisfaction surveys are given in all programs, which are reviewed with all staff.

26. All satisfaction surveys are reviewed by our senior management team and the CEO writes a note to every staff member who was mentioned in a positive way. • In residential programs, there are less negative comments about “staff attitude” or “disrespect from staff” and more positive comments about the “professionalism of staff” and “staff’s helpfulness”. • As client satisfaction goes up, more clients complete treatment, go on to aftercare, and less are administratively discharged.

27. Treatment engagement and decreasing no show rates. • If clients do not receive treatment, they will not get better • In our outpatient office, half of clients did not show for their intake appointment and another half did not come back for a second appointment. • By beginning treatment engagement over the telephone, instituting centralized scheduling so all clinician schedules are overseen by intake staff, ensuring that all clients leave with a scheduled appointment, and conducting appt. reminder calls, we decreased intake no-show rates to 19% and increased the percentage of people who return for a second appointment to 95%.

28. Administrative Discharges • A huge issue in residential treatment. • Often for ongoing drug use, but other factors are treatment non-compliance and getting into disagreements with staff, which can often be staff initiated. • Have made this an important issue with program managers. • Administrative discharges must be approved by program manager. • Review data monthly. • In many cases, a return to drug use does not result in a discharge.

29. Individualized Care • Attending to the multiple needs of clients. • Instituted a modified ASI in all programs. • Chart audits review the ASI Severity Index and ensure that identified problems are noted in the treatment plan and progress notes address identified problems. • Results are given to the clinicians, in an effort to ensure that care is individualized.

30. A focus on practice-based evidence • Obtaining feedback from clients on the treatment that is received may be a powerful way to enhance care. • A formalized process of asking clients: • Are they getting their needs met? • How is the quality of the therapeutic alliance?

31. Have begun an initiative on training clinicians to ask clients if the treatment is useful and if not, what would make it more useful. • In one program, clients reported that in many groups, there was too much cross-talk and that more structure/information would be useful. • Feedback was given to the clinicians and they are working to modify their approach.

32. Developed a survey that asked clients why they relapsed. • Survey results were aggregated and discovered the most relevant reasons why our clients relapsed. • Developed groups that addressed these specific reasons and trained staff.

33. Are these groups evidence-based? • No....or not yet.....

34. Are these groups relevant and have they enhanced the quality of care? • We think so........

35. A Culture of Continuous Performance Improvement • All programs are involved in ongoing performance improvement activities using rapid cycle plan-do-study-act (PDSA) projects. • Can focus on anything!

36. Decreasing no show rates. • Increasing treatment retention rates. • Increasing the number of clients who get involved in an educational or vocational program. • Decreasing episodes of aggressive acting-out. • Increasing referrals to the program. • Increasing overall treatment compliance. • Increasing satisfaction with group therapy.

37. In a short term residential treatment program (LOS about 15-30 days), it was found that 75% of people who left treatment early did so in the first five days of treatment. • Developed a new client fact sheet that reviewed what would occur in treatment and what to expect. • Worked with Case Managers to try to meet with their clients more quickly. • Reduced the % of clients who left treatment early within the first five days to 37%.

38. In a working halfway house, we found that only 38% of clients were able to obtain work within the first 30 days of treatment. • Trained staff in a Job Seekers Workshop. • Extended the time clients needed to return to the program. • Over four months, 81% of clients were able to obtain work within the first 30 days of treatment.

39. Summary • The goal of evidence-based practices is to enhance the effectiveness of care and to provide clients the best possible treatment. • However, the delivery of evidence-based practices is just one piece of the pie. • Let us not forget the many other ways to enhance the quality of care that is delivered for clients with SUDs.