1

Using Evidence Based

Interventions

Stephen Brazill, MA, MAC

Agenda

Brief History Some things about research EBTs Implementation Resources

2

3

History

Where Have We Been?

4

History

Mid 1930s Alcoholics Anonymous

1950s Narcotics Anonymous

The 1970s Hughes Act Research was scarce Knowledge mostly folk science For severe and chronic clients

5

History

1980s Drug Free Workplace Act EAPs Inpatient centers grew and prospered

1990s Institute of Medicine report Disconnect between research and

practice Bridging the Gap

6

Today

Building the bridge Evidence-based treatments Outpatient treatment Continuum of addictive behaviors

None Mild Moderate Severe

7

Now and Future

Ongoing research in academic and community settings

Improving dissemination of innovation

Improving implementation of evidence-based treatments

Client driven Outcome driven Maintenance vs. acute model

8

Now and Future Increased intervention via non-

specialist systems Health systems Social systems

The barber shop? Dentist? Religious communities Schools systems

New(er) Delivery systems Internet (meetings, chat room, Second

Life, etc.) Cell phone

9

Does Treatment Work?

Wrong

Questi

on

10

What Treatments Work?

11

What Does “Work” Mean?

Abstinence? Reduced use? Reduced psychiatric problems? Reduced incarceration? Increased employment? Reduced medical problems? Improved family functioning?

12

What Treatments Work?

For what clients?At what time?

Delivered by who?

13

How Do We Tell If Treatments

Work?

14

Levels of Evidence

Randomized clinical trials Quasi-experimental studies Correlational studies Anecdotal case reports, professional

opinion, best practice guidelines developed by consensus

15

Research Definitions

Efficacy Effectiveness

16

Problems With Research

Uni-directional Chosen by researchers Controlled settings Specific populations Individual counseling

17

Problems With Research

Training (cost, time, follow-through, drift)

Dissemination Less than 50% of programs are using

proven psychosocial interventions 10-17 years for dissemination

18

Solutions

Practice to research Clinical Trials Network Outcome research in community

programs Leadership focus on evidence-based

program development and training

19

How Research Helps Us Help

Others

20

What Research Does For Us

Helps clarify, guide and inform practice

Answers questions Improves outcomes Helps correct for human self-

deception “Addictive personality” Confrontation Victim impact panels

21

What Research Does For Us

Dispels myths such as…… Nothing works One approach is superior to another Everything works equally well

22

Why Use Evidence-Based Treatments?

Ethical and humanitarian considerations

Public interest and moral obligation Particularly when treatment is

coerced

23

Absence of Studies Does Not

Mean That a Treatment Does

Not Work

24

Respect Research, But

Do Not Revere It

EBTs Vs. EBP

Evidence Based Treatment Motivational Interviewing

Evidenced Based Practice Allowing mothers to take kids with

them to treatment Hiring empathic counselors

25

26

A Brief Review of Some Research

Findings

27

Miller & Hester 1995: Alcohol

Top Brief intervention Social skills training Motivational enhancement Community reinforcement approach Behavior contracting

Bottom Relaxation training Confrontation Psychotherapy General alcoholism counseling Education

28

Miller & Hester 2003: Alcohol (adapted post

COMBINE)Top

Brief intervention Motivational enhancement Community reinforcement approach Self-change manual Opiate Antagonists (Naltrexone) BSCT

Bottom Relaxation training Confrontation Psychotherapy General alcoholism counseling Education

29

Miller, Zweben & Johnson 2005

Cognitive-behavioral treatment Community reinforcement approach Motivational interviewing Relapse prevention Social skills training

JSAT 29 (2005)

30

Overview of Treatment Methods

Build client motivation, readiness and engage

Cognitive and behavior skills Increasing positive rewards for non-

use Involve family and social networks

Think outside the skin Appropriate medications

A Resource

Understanding Research Concepts: A Guide for Counselors

http://www.danya.com/dlc/courselist.asp

31

Building Motivation, Readiness,Engaging

32

33

Important Client Factors

Goals Values Experiences Expectations Strengths Cultural, ethnic and spiritual

background Biology Motivation & readiness

Assessi

ng and

Utilizin

g

34

Stages of Change

Precontemplation Contemplation Preparation Action Maintenance

Prochaska, Norcross, DiClemente

Relapse

35

Stages of Change

80% of substance abusers are in precontemplation or contemplation

Define success by the movement from one stage to the next

36

Predicting Change

in Clients

37

Predicting Change

Adherence to change efforts Self-efficacy Self-reported motivation Engagement and retention Quality of counseling relationship Client speech

38

Counselors and Helpers

39

HARPWhat We Believe and Do Matters

40

Building Motivation

41

Influencing Motivation:What Doesn’t Work

Enlightenment Education Insight-oriented persuasion

Confrontation Punishment

42

Building Motivation:What Works

43

Helper Traits That Help...…

A Lot Accurate empathy Genuine Unconditional positive regard

44

Appears that the counselor to whom one is assigned makes considerably more difference than the specific treatment employed*

*Najavits & Weiss, 1994

45

Interpersonal Influence

Referral from your office 2X Call or handwritten note 2X Missed session/letter ½

drop out AA w/member support 100% AC reminder calls/calendar 2X

46

Motivation

Is not a static client trait Affected greatly by relationship with

counselor It is interpersonal Measured by client language and

observed behavior

47

Change Talk

D = Desire for Change (want, wish, like) A = Ability to Change (could, can) R = Reasons for Change (if……then…..) N = Need for Change (need, have to, got to)

C = Commitment to Change (intention, decision)A = Activation (ready, prepared, willing)T = Taking Steps (tossed out cigarettes)

Motivational Interviewing Is…..

Motivational interviewing is a collaborative, person-centered, form of guiding

to elicit and strengthen motivation for change

Miller & Rollnick (2009)

Motivational Interviewing

Helps increase client change and commitment talk

Helps reduce resistance Helps engage clients Plays well with other treatments

Synergistic effects

50

Community Reinforcement Approach

52

Community Reinforcement Approach

(CRA) Broad spectrum behavioral

treatment Creating ways to reward sober

behavior Positive reinforcement

Utilizing social, recreational, familial and vocational reinforcers

Changing the person’s sources of reinforcement in the community

CRA Components

Job Finding Behavioral marital

therapy Social/leisure

counseling Social club Medication Problem-solving Sober buddy

system

Motivational counseling

Sobriety sampling Drink refusal Immediate

disulfiram administration

Relaxation training

53

54

1 Using/Sobriety 1 2 3 4 5 6 7 8 9 10

2 Job or Educational Progress 1 2 3 4 5 6 7 8 9 10

3 Money Management 1 2 3 4 5 6 7 8 9 10

4 Social Life 1 2 3 4 5 6 7 8 9 10

5 Personal Habits 1 2 3 4 5 6 7 8 9 10

6 Marriage/Family Relationships

1 2 3 4 5 6 7 8 9 10

7 Legal Issues 1 2 3 4 5 6 7 8 9 10

8 Emotional Life 1 2 3 4 5 6 7 8 9 10

9 Communication 1 2 3 4 5 6 7 8 9 10

10 General Happiness 1 2 3 4 5 6 7 8 9 10

Completely Completely Happy Unhappy

Happiness Scale

55

Thinking Outside

The Skin

56

Systemic View For every individual with an alcohol

problems, 5 others suffer directly Violence & verbal aggression Unpredictable & embarrassing

behavior Stealing from family Depressed mood, lowered self-

confidence Physical complaints

57

Motivation Individuals with substance abuse

problems often report that their decision to enter treatment was prompted by direct influence of CSOs or CSOs acting in concert with others

Success rates for treatment entry when CSOs are directed by professionals:

24% to 86%

Community Reinforcement and Family Training: CRAFT

59

Community Reinforcement and

Family Training (CRAFT) Outgrowth of CRA Assumes that CSOs can play a

powerful role in effecting change Does not assume that CSOs are

responsible for use’s behavior CSOs can benefit from assistance in

learning to take better care of themselves

60

Unique Components

Emphasis on safety issues Reliance on functional analysis Identifying and utilizing reinforcers

for both the drinker and CSO Emphasis on personal lifestyle

changes Skills training from CRA

61

The Other Benefits

CRAFT-trained CSO functioning from baseline to 3 months showed decreased: anger anxiety depression

Regardless of whether or not the substance user had entered treatment

62

CRAFT Procedures

Domestic violence precautions Functional analysis Communication training Use of positive reinforcement Time out from positive

reinforcement

Natural consequences for using Reinforcers for the CSO Suggestion of treatment Rapid intake procedures

The Numbers

Randomized into: Ala-non 13% Johnson Institute intervention 23% CRAFT 67%/76%

64

Promoting Awareness of Motivational Incentives

Seven Principles Target behavior Choice of target population Choice of reinforcer Incentive magnitude Frequency of incentive distribution Timing of the incentive: Duration of the intervention

65

What Do You Get…..

When you take an effective

intervention and implement it in an ineffective way?

66

67

The Joy of Implementation

Stages of Implementation

Exploration and adoption Program installation Initial implementation Full operation Innovation Sustainability

Implementation Research: A Synthesis of the Literature

Fixsen, et. al. 68

69

Considerations

Provider, agency or system culture and readiness

Buy-in on multiple levels Delivery systems (in-person, manual-

driven, etc.) Staff selection Training design and systems Follow through Supervision, mentoring and

coaching

70

Considerations

Costs Mandated use of EBTs??? Policy or mission statements

A Few Resources(more are in the resources

handout)

71

Big Picture View

Rethinking Substance Abuse: What the Science Shows and What We Should Do About It

William R. Miller and Kathleen M. CarrollGuilford Press 2006

72

EBTs

http://www.nrepp.samhsa.gov/index.asp

http://www.drugabuse.gov/blending/

73

Implementation

http://www.fpg.unc.edu/~nirn/resources/detail.cfm?resourceID=31

Fixsen, et. al.

74

Summary

Anything goes is gone No superior approach for all

individuals Variety of approaches work Different people respond to different

approaches Therapeutic relationship is of GREAT

importance Client goals, values, experiences and

cultural background are important75

76

Summary

Treatment programs should offer a variety of evidence-based treatments

Staff should receive training in evidence-based treatments and their work should be observed

Programs need to measure their outcomes

Effective implementation is vital and often overlooked in the process of putting EBTs into practice

77

What Really Matters…..

Its is not the amount or setting of treatment

as much as the method of treatment who provides it and how they relate

From W.R. Miller: “Motivation for Change: 25 Years of Unexpected Findings and Their Implications for Treating Addictions”

Thanks for playing along….

Stephen Brazill, MA, MACRiverside Group, LLC

316 304-5272sbrazill@riversidegroupconsul

ting.com

78