a conceptual model for treatment...

A Conceptual Model for Treatment ProcessesDr. Dwayne Simpson and Dr. Patrick FlynnTexas Christian University

NIDA Meeting on Treatment & Recovery ProcessesWashington, DCJanuary 15, 2004

© 2004 TCU Institute of Behavioral Research, Fort Worth, Texas. All rights reserved.IBR Web site: www.ibr.tcu.edu of 20

A Conceptual Model A Conceptual Model for Treatment for Treatment

ProcessesProcessesDwayne Simpson & Patrick FlynnDwayne Simpson & Patrick Flynn

TCU Institute of Behavioral ResearchTCU Institute of Behavioral ResearchFort Worth, TexasFort Worth, Texas

Meeting on Treatment & Recovery Processes(Jan 15-16, 2004; Wash DC)

Positive Outcomes

Program Program StructureStructure

Organizational Organizational ClimateClimate

Program Program ResourcesResources

TreatmentTreatmentProcessProcess

ProgramProgramChangeChange

Systems Infrastructure for Systems Infrastructure for Treatment Monitoring and ChangeTreatment Monitoring and Change

Program Change ModelProgram Change Model

ProgramChange


Organizational DynamicsOrganizational Dynamics

Institutional & Institutional & Personal ReadinessPersonal Readiness

ResourcesResourcesResourcesMotivationMotivationMotivation

Climatefor Change

ClimateClimatefor Changefor Change Staff

AttributesStaffStaff

AttributesAttributes InstitutionalSupports

InstitutionalInstitutionalSupportsSupports

Reception& Utility

ReceptionReception& Utility& Utility

Time & Place

Time & Time & PlacePlace

Simpson, 2002 (J Substance Abuse Treatment)

Stages of TransferStages of TransferStages of Transfer1-Exposure

(Training)• Lecture• Self Study• Workshop• Consultant

11--ExposureExposure((TrainingTraining))

•• LectureLecture•• Self StudySelf Study•• WorkshopWorkshop•• ConsultantConsultant

StaffStaffStaff 2-Adoption(Leadership decision)22--AdoptionAdoption(Leadership decision)(Leadership decision)

4-Practice(Routine use)44--PracticePractice(Routine use)(Routine use)

3-Implementation(Exploratory use)33--ImplementationImplementation(Exploratory use)(Exploratory use)


ProgramChange





Climatefor Change





Reception& Utility


Time & Place










ProgramProgramProgramStaffStaffStaff

ResourcesResourcesResources

ClimateClimateClimate

PatientPatientPatientSeveritySeveritySeverity

ReadinessReadinessReadiness

PosttreatmentPosttreatment

DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations

SocialSocialRelationsRelations

EvidenceEvidence--Based Treatment ModelBased Treatment Model

SupportiveNetworks

SupportiveSupportiveNetworksNetworks

Simpson, 2001 (Addiction)

SufficientRetentionSufficientSufficientRetentionRetention

Early Early RecoveryRecovery

Change: BehavioralChange: Change:

BehavioralBehavioral

Change: Psycho-Social

Change: Change: PsychoPsycho--SocialSocial

TherapeuticRelationshipTherapeuticTherapeuticRelationshipRelationship

ProgramParticipation

ProgramProgramParticipationParticipation

Early Early EngagementEngagement

Retention/ Retention/ TransitionTransition

CognitiveCognitiveInterventionsInterventions

BehavioralBehavioralInterventionsInterventions

Recovery SkillsRecovery SkillsTrainingTraining

Social SkillsSocial Skills& Support& Support

ReadinessReadinessInterventionsInterventions

Social Support Social Support ServicesServices

Personal Health Personal Health ServicesServices

SystemsSystemsInterventionsInterventions







DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations



SupportiveNetworks

























Patient Retention Rates for ProgramsPatient Retention Rates for Programs(beyond minimum “thresholds”)(beyond minimum “thresholds”)

65%75% 76%

21% 16% 15%3+ Mos inLong-TermResidential

(n=17)

3+ Mos in Outpatient Drug-Free

(n=14)

12+ Mos inOutpatient

Methadone (n=10)

Simpson, Joe, Broome, Hiller, Knight, & Rowan-Szal, 1997 (PAB)

BestProgram

PoorestProgram

DATOS

Counseling Counseling RapportRapport(% with (% with HIGHHIGH Scores in 12 Programs)Scores in 12 Programs)

35%38%

43%47% 48% 48%

53%59% 61% 61%

66% 69%

1 2 3 4 5 6 7 8 9 10 11 12

TCU/NF-ATTC Survey (April 2001; “High” scores = >40)

LowestLowest HighestHighest




“Black Box” of Treatment“Black Box” of Treatment



DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations


Changes inChanges in ––•• CognitiveCognitive•• BehavioralBehavioral•• PsychologicalPsychological•• Social functioningSocial functioning

Integrate & Strengthen Integrate & Strengthen for Recovery ?for Recovery ?

AdequateStay in Trt


DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations



TherapeuticRelationship

BehavioralChange

CognitiveChange

PatientReadiness/Motivation

Stages of Treatment Process Stages of Treatment Process

Use Use TargetedTargeted InterventionsInterventions

Early Recovery

Early Engagement

Retention/ Transition

Joe & Simpson, in review




Induction to TreatmentInduction to Treatment(Readiness Training)(Readiness Training)

Simpson & Joe, 1993 (Pt); Blankenship et al.,1999 (PJ); Sia, Dansereau, & Czuchry, 2000 (JSAT)

SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness


Contingency ManagementContingency Management(Token Rewards)(Token Rewards)

Rowan-Szal et al., 1994 (JSAT); 1997 (JMA); Griffith, Rowan-Szal et al., 2000 (DAD)

SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness





Counseling EnhancementsCounseling Enhancements(Cognitive “Mapping”)(Cognitive “Mapping”)

Dansereau et al., 1993 (JCP), 1995 (PAB); Joe et al., 1997 (JNMD); Pitre et al., 1998 (JSAT)

SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness


SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientAttributesat Intake

Motiv

Specialized InterventionsSpecialized Interventions(Skills(Skills--Based Counseling Manuals)Based Counseling Manuals)

Bartholomew et al., 1994 (JPD); 2000 (JSAT); Hiller et al., 1996 (SUM)

SupportiveNetworks





SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness

NIDA List of NIDA List of “Scientifically Based Approaches”“Scientifically Based Approaches”

Principles of Drug Addiction Treatment: A Research Based Guide (NIDA, 2000)

Motivational Enhancement Motivational Enhancement (ME)(ME)


SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness





Voucher Based Reinforcement TherapyVoucher Based Reinforcement Therapy


SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness


Matrix ModelMatrix Model

CognitiveInterventions

BehavioralInterventions

Recovery SkillsTraining

Social Skill& Support


SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness





Relapse PreventionRelapse Prevention

Recovery SkillsTraining

Social Skill& Support



SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness












PatientPatientPatient

SeveritySeveritySeverity



DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations



SupportiveNetworks










Client Client Treatment Treatment

plan ?plan ?




“Evidence“Evidence--Based” InterventionsBased” Interventions

SufficientRetention

Early Engagement

Early Recovery

Posttreatment

DrugUse

Crime

SocialRelations



BehavioralChange

Psycho-SocialChange

PatientSeverity

Readiness Reviewed & CategorizedReviewed & Categorizedin in Conceptual FrameworkConceptual Framework

for Stagefor Stage--Based TreatmentBased Treatment

CSAT/NREP






Clinical Performance MeasuresClinical Performance Measures



DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations















ProgramProgramProgram



StaffStaffStaff

MotivationMotivationMotivation




Problem Problem SeveritySeverityat Intakeat Intake(for Client(for Client

& Program)& Program)

100

41

34

73

70

75

55

64

Heroin

Cocaine

Alcohol

Needle Risks

Peer/Friends

Family

Psychological

Crimal Involv % of Clients

CLIENT PROBLEM PROFILECLIENT PROBLEM PROFILE

TCU BRIEF INTAKETCU BRIEF INTAKE DATE:

5/6/99

SITE:

1

CLIENT ID:

0999

AGE 41 EDUCATION 09GENDER Male

COCAINE

HEROIN/OPIATES

MARIJUANA

OTHER ILLEGAL DRUGS

ALCOHOL

SEX RISKS

PEERS/FRIENDS

FAMILY

PSYCHOLOGICAL

HEALTH

UNEMPLOYMENT

CRIMINAL INVOLVEMENT

MARITAL STATUS Separated

NO YES NO YES

NEEDLE USE RISKS

MULTIPLE (3+) DRUG USE

Client PROBLEM INDEX (Range 0-14) 1-4 5-6 7-8 9-14Low Mod High Extreme

RACE/ETHNICITY Mexican AmericanHI PRESSURE FOR TREATMENT Yes

HI NEED FOR TREATMENT Yes

8

LEGALLY MANDATED NoLEGAL STATUS Yes

TCU “Brief Intake”TCU “Brief Intake”•• Computer scoredComputer scored•• Client profilesClient profiles•• Treatment planningTreatment planning•• Program profilesProgram profiles

Client Client EngagementEngagement&& FunctioningFunctioningin Treatmentin Treatment

(for Client(for Client& Program)& Program)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DH M otiv

TR SE Psych

DP AX DM PM HS Soc ia l

RT SC TN TS TR TP PS SS

TCU Clien t Evaluation of Se lf & Treatment (CEST) ScalesTreatment Engagement ScalesTreatment Engagement Scales

Percentile Scores for Motivation/Percentile Scores for Motivation/PsychoSocialPsychoSocial Problems & Treatment ScalesProblems & Treatment Scales

Average ScoresAverage Scoresfor All Clientsfor All Clients

Client XXClient XX

ClientClient Functioning Profile During Functioning Profile During TrtTrt(Compared to Averages for Other Clients)(Compared to Averages for Other Clients)

0%

1 0%

2 0%

3 0%

4 0%

5 0%

6 0%

7 0%

8 0%

9 0%

1 0 0%

DH M o tiv

TR SE Psy ch

DP AX DM PM HS Soc ia l

RT SC TN TS TR TP PS SS

TCU C lien t Evaluation o f Se lf & T reatm en t (CEST ) S ca les

T o tal (n=7 97)A g 50 (n=29 )

Treatment Engagement ScalesTreatment Engagement Scales

ProgramProgram Functioning Profile During Functioning Profile During TrtTrt(Compared to Averages for Other Programs)(Compared to Averages for Other Programs)

% of Clients with Motivation/% of Clients with Motivation/PsychoSocialPsychoSocial Problems & High Treatment EngagementProblems & High Treatment Engagement

Joe, Broome, Rowan-Szal, & Simpson, 2002 (J Substance Abuse Treatment)

TCU “CEST” FormTCU “CEST” Form•• Computer scoredComputer scored•• Client profilesClient profiles•• Program profilesProgram profiles•• ““NormedNormed” comparisons” comparisons




Client Evaluation of Client Evaluation of Self & Treatment (CEST)Self & Treatment (CEST)

PsychosocialPsychosocialA.A. MotivationalMotivationalB.B. PsychologicalPsychologicalC.C. SocialSocial

Treatment EngagementTreatment EngagementA.A. Treatment ParticipationTreatment ParticipationB.B. Treatment SatisfactionTreatment SatisfactionC.C. Counseling RapportCounseling Rapport

D.D. Peer Support Peer Support (Clients)(Clients)

E.E. Social SupportSocial Support(Family/Friends)(Family/Friends)

•• 3030--min min (Self(Self--Admin)Admin)•• 66--8 item scales8 item scales•• Scores = 10Scores = 10--5050

(5(5--pt Agreept Agree--Disagree)Disagree)•• αα = .70 = .70 -- .90.90•• Validity evidenceValidity evidence

Joe, Broome, Rowan-Szal, & Simpson, 2002 (J Substance Abuse Treatment)

NEWNEW CJ Criminal Thinking ScalesCJ Criminal Thinking Scales

10

15

20

25

30

35

40

45

50

Needs

Indx

S Este

em

Depre

ss-

Anxiet

y-

Dec M

ak

S Effic

acy

Hostili

ty-

Risk Ta

k-

Soc C

onsc

Satisfa

c

Rappo

rt

Partici

p

Peer S

upp

Fam S

upp

TCU Client Evaluation of Self & Treatment (CEST) Scores

118-1118-2118-3b

Client Functioning ProfilesClient Functioning Profiles(During(During--Treatment Progress in CJ Program)Treatment Progress in CJ Program)

Engagement ProgressEngagement ProgressPsychological ProgressPsychological Progress Social ProgressSocial Progress




Client Functioning SummaryClient Functioning Summary(During(During--Treatment Progress in CJ Program)Treatment Progress in CJ Program)

Engagement ProgressEngagement ProgressPsychological ProgressPsychological Progress Social ProgressSocial Progress

10

15

20

25

30

35

40

45

50

Needs

Indx

S Este

em

Depress

-

Anxiet

y-

Dec M

ak

S Effic

acy

Hostilit

y-

Risk Tak

-

Soc C

onsc

Satisfa

c

Rappo

rt

Partici

p

Peer S

upp

Fam S

upp


Trt IntakeCompletion (3c)

Positive Outcomes





ProgramChange





Climatefor Change





Reception& Utility


Time & Place





11--ExposureExposure((TrainingTraining))•• LectureLecture•• Self StudySelf Study•• WorkshopWorkshop•• ConsultantConsultant





ProgramChange





Climatefor Change





Reception& Utility


Time & Place















DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations



SupportiveNetworks




























DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations



SupportiveNetworks


























ProgramImprovement(Services/Process/

Management)

ProgramProgramImprovementImprovement(Services/Process/(Services/Process/

Management)Management)




Climatefor Change





Reception& Utility



Stages of ChangeStages of ChangeStages of Change

1-Exposure(Training)

• Lecture• Self Study• Workshop• Consultant






•• MonitoringMonitoring•• FeedbackFeedback•• RewardsRewards

•• SatisfactionSatisfaction•• Ease of useEase of use•• Values fit Values fit

Organizational Organizational Functioning Functioning &&

ReadinessReadiness(based on(based on

Staff ratings)Staff ratings)10

15

20

25

30

35

40

45

50

PrNMotiv

TrN Prs OffRe s

Stf Tr$ PC s EM G rwStaff

E ff Inf A dp MisClim

C oh Auto C om Str- C hg

TCU Organ ization al Readiness for Change (O RC) S cales

Tota l (n=112 )A g 27 (n=3)

Organizational Functioning Profile Organizational Functioning Profile (Compared to Total Sample of NF(Compared to Total Sample of NF--ATTC Treatment Staff)ATTC Treatment Staff)

Mean ScoresMean Scores

24

28

28

31

33

36

37

37

39

39

39

39

1

2

3

4

5

6

7

8

9

10

11

12

LowestLowest

HighestHighest

MidMid--point point on Scaleon Scale

Sample Scores for 12 programs

Staff Cohesion ScoresStaff Cohesion Scores

Lehman, Greener, & Simpson, 2002 (J Substance Abuse Treatment)

TCU “ORC” SurveyTCU “ORC” Survey•• Web basedWeb based•• Program profilesProgram profiles•• Program comparisonsProgram comparisons•• ““NormedNormed” comparisons” comparisons




Organizational FunctioningOrganizational Functioning


DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations


















StaffStaffStaff







StaffStaffStaff


ResourcesResources•• Offices/StaffingOffices/Staffing•• TrainingTraining•• EquipmentEquipment StaffStaff::

•• GrowthGrowth•• EfficacyEfficacy•• InfluenceInfluence•• AdaptabilityAdaptability•• OrientationOrientation

ClimateClimate::•• MissionMission•• CohesionCohesion•• AutonomyAutonomy•• Communication Communication •• StressStress•• ChangeChange

MotivationMotivation•• Program NeedsProgram Needs•• Training NeedsTraining Needs•• PressuresPressures





Org. Climate: Org. Climate: CohesionCohesion(Average scores (Average scores –– range 10range 10--50)50)

24

28

28

31

33

36

37

37

39

39

39

39

1

2

3

4

5

6

7

8

9

10

11

12

LowestLowest

HighestHighest

TCU/NF-ATTC Survey (April 2001)

MidMid--point point on Scaleon Scale

12 programs at TCU Workshop

ClientClientFunctioning?Functioning?





StaffStaffStaff


Lehman, Greener, & Simpson, 2002 (J Substance Abuse Treatment)












Staff Staff LevelsLevels

Client Rating•Rapport•Satisfaction

Client RatingClient Rating••RapportRapport••SatisfactionSatisfaction

Counselor RatingCounselor Rating••MissionMission••CohesionCohesion••CommunicationCommunication••AutonomyAutonomy••Open to changeOpen to change





10

15

20

25

30

35

40

45

50

PrgNee

ds

TrtN

eeds

Pressu

re

Offices

Staff

Trn $

PCs

Intern

et

Growth

Efficac

y

Influe

nce

Adapt

Mission

Cohes

ion

Autono

my

Comm

Stress

-

Chang

e

TCU Organizational Readiness for Change (ORC) Scores

Prog 311-1L (n= 7)Prog 333-1L (n= 8)

Organizational FunctioningOrganizational FunctioningComparison of Comparison of HighHigh vs vs LowLow CBT ProgramsCBT Programs

Motivation Resources Staff Attributes Climate

20

25

30

35

40

45

50

Desire

Help

More T

rt

Need I

ndx

S Este

em

Depre

ss--

Anxiet

y--

Dec M

ak

S Effic

acy

Hostili

ty--

Risk Ta

k--

Soc C

onf

Partici

p

Satisfa

c

Rappo

rt

Peer S

upp

Fam S

upp


Prg 314-1LPrg 316-1LPrg 317-2LPrg 336-1L

Client FunctioningClient FunctioningComparison of Diverse Set of CBT ProgramsComparison of Diverse Set of CBT ProgramsTrtNeedsTrtNeeds Engagement ProgressEngagement ProgressSocial ProgressSocial ProgressPsychological ProgressPsychological Progress




ORC &ORC &CESTCEST

6-9 MosAfter

Org/ClientOrg/ClientFunctioningFunctioning

Tracking & Evaluating ChangeTracking & Evaluating Change

ABCD

WAFUWAFU

3-4 MosAfter

TrainingTrainingAdoptionAdoption

3-4 MosBefore

ORC &ORC &CESTCEST


6 MosBefore

PTNPTN

ProgramProgramNeedsNeeds

B

D

A

C

Do those who “want/need” Do those who “want/need” certain training attend?certain training attend?

EvaluationEvaluation

Training

TrainingTrainingPlansPlans

ORC &ORC &CESTCEST

6-9 MosAfter



ABCD

WAFUWAFU

3-4 MosAfter


3-4 MosBefore

ORC &ORC &CESTCEST


6 MosBefore

PTNPTN


B

D

A

C


Training

Is Is quality of trainingquality of training(satisfaction & value fit)(satisfaction & value fit)related to its adoption?related to its adoption?




ORC &ORC &CESTCEST

6-9 MosAfter



ABCD

WAFUWAFU

3-4 MosAfter


3-4 MosBefore

ORC &ORC &CESTCEST


6 MosBefore

PTNPTN


B

D

A

C


Training

Is Is program functioningprogram functioning(staff & clients) related (staff & clients) related to adoption of training?to adoption of training?

ORC &ORC &CESTCEST

6-9 MosAfter



ABCD

WAFUWAFU

3-4 MosAfter


3-4 MosBefore

ORC &ORC &CESTCEST


6 MosBefore

PTNPTN


B

D

A

C


Training

Did “Did “program improvementsprogram improvements” ” (staff & clients) follow(staff & clients) followadoption of training?adoption of training?




ORC &ORC &CESTCEST

6-9 MosAfter



ABCD

WAFUWAFU

3-4 MosAfter


3-4 MosBefore

ORC &ORC &CESTCEST


6 MosBefore

PTNPTN


B

D

A

C


Training

Are Are program needs & structureprogram needs & structurerelated to how well staff adapt related to how well staff adapt

changes into longchanges into long--term practice?term practice?

Program Change ProcessProgram Change Process[If Client Engagement (1) was ‘Mod[If Client Engagement (1) was ‘Mod--Low’]Low’]

ClientEngagement

(2)

ClientClientEngagementEngagement

(2)(2)

• Satisfaction• Ease of use• Values fit

Reception& Utility


Sf EU VF

TrainingImplementation

(Exploratory use)

TrainingTrainingImplementationImplementation

(Exploratory use)(Exploratory use)


Of St Tr• Office• Staff• Training


PN TN Pr

• Pgr Needs• Trn Needs• Pressures Pt Sf Rp

• Participation• Satisfaction• Rapport

Organizational ChangeOrganizational ChangeClimate (2)Climate (2)Climate (2) Climate (1)Climate (1)Climate (1)

Coh Cm Chg Coh Cm Chg

• Cohesion• Commun.• Change

PTNPTN ORCORC(1)(1) / WAFU / WEVAL/ WAFU / WEVAL ORCORC(2(2--1)1) / CEST/ CEST(2)(2)




Positive Outcomes

Program Program StructureStructure

Organizational Organizational ClimateClimate

Program Program ResourcesResources





ProgramChange





Climatefor Change





Reception& Utility


Time & Place










ProgramChange





Climatefor Change





Reception& Utility


Time & Place















DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations



SupportiveNetworks




























DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations



SupportiveNetworks






















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Posttreatm entPosttreatment

DrugUse

DrugDrugUseUse

CrimeCrimeCrime

Socia lRelations

SocialSocia lRelationsRelations




BehavioralChange

BehavioralBehavioralChangeChange

Psycho-SocialChange

PsychoPsycho--SocialSocialChangeChange


CognitiveCognitiveStrateg iesStrategies

BehavioralBehavioralStrateg iesStrategies

Social SkillsSocial SkillsTrainingTraining

Family &Family &FriendsFriends

SupportiveNetworks


Personal Health ServicesPersonal H ealth Services

Social Support ServicesSocial Support Services


ProgramProgramInterventionsInterventions

R eadinessReadinessTrainingTraining

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