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