Planning for Effective Planning for Effective

Treatment Services and Treatment Services and

Implementing ChangeImplementing Change

Dwayne Simpson

Congress on AddictionsCongress on Addictions : Quebec : Quebec Association of Addiction Rehab CentersAssociation of Addiction Rehab CentersMAY 14, 2010, MONTREAL, CANADAMAY 14, 2010, MONTREAL, CANADA

Sustaining & improving services?Sustaining & improving services?

•• CalibrateCalibrate needs & servicesneeds & services for clients for clients (care plans)(care plans)

� Triage clients into intensity levels (especially CJ)

•• Sustain Sustain effective effective treatment system & processtreatment system & process� Assessments & Interventions that work & inter-connect

•• TranslateTranslate local/national local/national policy statementspolicy statements� Special care mandates & resource streams

•• AttendAttend to to organizational climate/functioningorganizational climate/functioning

© 2010

““How do we keep doing How do we keep doing more with less more with less and and also show also show favorable favorable evidenceevidence for outcomesfor outcomes””??

Check ListCheck List for System Effectivenessfor System Effectiveness

1. Are current assessments reliable measuresof client needs and stages of change?

2. Do current interventions show measureable evidence of effectiveness (related to needs)?

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 limit operational/performance levels?

© 2010

•• DARP DARP (1st US Study 1970s)•• TOPSTOPS (2st US Study 1980s)•• DATOSDATOS (3rd US Study 1990s)

300+ Studies Published on 65,000 Drug Users Treated

in over 300 Programs

www.DATOS.org

NIDANIDA’’s National Evaluations of s National Evaluations of

Treatment Effectiveness in U.S.Treatment Effectiveness in U.S.

ProcessProcessProcessProcessProcessProcessProcessProcess

matters!!!matters!!!matters!!!matters!!!matters!!!matters!!!matters!!!matters!!!© 2010

No-Trt vs . Trt (Retention ) Grps

% R

elap

se

• Tired of the hassle – “hitting bottom” …(intra-individual )

• Health/medical problems, religion …• Special events – getting married, family needs

(inter-personal )• Fear of jail/violence …

(environmental )

Pathways to RecoveryPathways to Recovery((A 12A 12--Year FollowupYear Followup, , Simpson & Sells, 1990))

© 2010

Starting placeStarting place and and route of travel route of travel differs across individuals!!differs across individuals!!

Follow-upOutcomes• Drug use• Crime• Social

Functions

FollowFollow --upupOutcomesOutcomes•• Drug useDrug use•• CrimeCrime•• Social Social

FunctionsFunctions

Other Treatments

or Support

Networks

Other Other Treatments Treatments

or or Support Support

NetworksNetworks

Early Early EngagementEngagement•• ParticipationParticipation•• Therapeutic Therapeutic RelationshipRelationship

TreatmentReadiness:• Needs-

Risk• Severity• Motivation

TreatmentTreatmentReadiness:Readiness:•• NeedsNeeds --

RiskRisk•• SeveritySeverity•• MotivationMotivation

Early Early RecoveryRecovery

Changes in Changes in ----•• ThinkingThinking•• ActingActing

RetentionRetention & & Continuing Continuing

ChangeChange

““ AdaptiveAdaptive ”” Treatment ApproachTreatment Approach

Assessments of Client Needs/ProgressAssessments of Client Needs/ProgressAssessments of Client Needs/Progress

Simpson, 1995, 2001, 2004, 2006© 2010

Interventions (Behavioral & Cognitive)Interventions Interventions (Behavioral & Cognitive)(Behavioral & Cognitive)

TCU Mapping: A Visual Representation StrategyTCU Mapping: A Visual Representation Strategy

© 2010

Information

Information

Information

Information

Exchange

Exchange

Exchange

Exchange

Group

Group

Group

Group

Discussion

Discussion

Discussion

Discussion

Linking Events &

Linking Events &

Linking Events &

Linking Events &

Consequences

Consequences

Consequences

Consequences

Decision

Decision

Decision

Decision----M

aking

Making

Making

Making

Strateg

ies

Strateg

ies

Strateg

ies

Strateg

ies

Cognitive science provides Cognitive science provides foundations for using visual tools foundations for using visual tools

(e.g., (e.g., ““ nodenode --link mappinglink mapping ”” ) for ) for communication & decisioncommunication & decision --makingmaking

Dansereau, Dees, & Simpson, 1994 (JCP)Dansereau & Simpson, 2009 (PPRP)

• Low education• Attention deficits• Language deficits

“TCU Mapping-Enhanced Counseling”

TCU Mapping: A Visual Representation StrategyTCU Mapping: A Visual Representation Strategy

Family W

ork

Applications Research

Fort WorthTexas

Dwayne

8Grand kids

Married& 3 Children

TCU NIDA Grants

AddictionStudies

StrategicPlanning

WestTexas

IBR (1962)

© 2010

Leadership Mission

Conceptual Integration Innovation

Selections

CJ/Adolescent CJ/Adolescent ServicesServices

TCU Mapping: A Visual Representation StrategyTCU Mapping: A Visual Representation Strategy

© 2010

•• ““ FreeFree--stylestyle ”” mapsmaps

•• ““ InformationInformation ”” mapsmaps

•• ““ GuidedGuided ”” mapsmaps

Fired!!Fired!!‘Maps’ help place

events into records with visual context for discussion of

impact and action.

For more info on For more info on

Mapping Training Mapping Training

(June 22(June 22--24) 24)

in in Fort Worth, TexasFort Worth, Texas

SelectedPresentations

IBR HOME PAGE

IBRA National Research Center A National Research Center

for addiction treatment studiesfor addiction treatment studiesin community and correctional settingsin community and correctional settings(over 600 free resource files available)(over 600 free resource files available)

DATOSDATOSDATOS

ProgramProgramProgram

StaffStaffSta ff

Reso urcesResourcesResources

ClimateClimateClimate

PatientPatientPatient

SeveritySeveritySeve rity

Read inessReadinessReadiness

SufficientRetentionSufficientSufficientRetentionRetention

Early Early EngagementEngagem ent

Early Early RecoveryRecovery

PosttreatmentPosttreatment

DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations

SocialSocialRe lationsRela tions

ProgramParticipation

ProgramProgramParticipationParticipat ion

TherapeuticRelat ionship

Therapeut icTherapeuticRelationshipRelationship

Behav ioralChange

Behaviora lBehavioralChangeChange

Psycho-SocialChange

PsychoPsycho --SocialSocialChangeChange

EvidenceEvidence --Based Treatment ModelBased Treatment Model

CognitiveCognitiveStrategiesStrategies

BehavioralBehavioralStrategiesStrategies

Social SkillsSocial SkillsT ra iningT raining

F amily &Family &FriendsF riends

SupportiveNetworks

SupportiveSupport iveNetw orksNetworks

Personal Health ServicesPersonal Health Services

Social Support ServicesSocial Support Services

Simpson, 2001 (Addiction)

Pro gramProgramInte rventionsInterventions

ReadinessReadinessTrainingT raining

SUMMARY

TCU Mapping-Enhanced Counseling

TreatmentProcess

CounselingManuals

Corrections-Based

Treatment

NationalEvaluations

OrganizationalReadiness

AssessmentFact Sheets(with norms)

www.ibr.tcu.eduwww.ibr.tcu.edu

EVIDENCE

MANUALS

FORMS

EVIDENCE

ABOUT IBR-TCU

STAFF

PUBLICATIONS

PRESENTATIONS

PROJECTS

NEWSLETTERS

OTHER LINKS

WHAT’S NEW

SITE GUIDES:

© 2010

Stages of TreatmentStages of Treatment

RetentionRetention& Change& Change

Early Recovery

Changes in • Thinking• Acting

Early Early RecoveryRecovery

Changes in Changes in •• ThinkingThinking•• ActingActing

EarlyEngagement• Participation• Therapeutic Relationship

EarlyEarlyEngagementEngagement•• ParticipationParticipation•• Therapeutic Therapeutic RelationshipRelationship

TreatmentReadiness:

• Needs-Risks

• Severity• Motivation

TreatmentTreatmentReadiness:Readiness:

•• NeedsNeeds --RisksRisks

•• SeveritySeverity•• MotivationMotivation

TargetedTargeted Interventions (with Interventions (with ““MappingMapping””) )

for for AdaptiveAdaptive Treatment ProcessTreatment Process

OrientationOrientation ReRe--EntryEntry

MappingMappingJourneyJourney

WorkshopWorkshopfor Menfor Men

TransitionTransitionto Reto Re --entryentry

Using ClientUsing ClientAssessmentsAssessments

MappingMappingCare PlansCare Plans

DownwardDownwardSpiralSpiral

Mapping Mapping ’’12 Steps12 Steps ’’

ParentingParentingSkillsSkills

WorkshopWorkshopfor Womenfor Women

Treatment ATreatment A Treatment BTreatment B

PreparingPreparingfor Changefor Change

GettingGettingMotivatedMotivated

CM/RewardCM/RewardStrategiesStrategies

BuildingBuildingNetworksNetworks

BetterBetterCommComm

HIV RiskHIV RiskReductionReduction

UnlockingUnlockingThinkingThinking

ReducingReducingAngerAnger

“TCU Mapping-Enhanced Counseling”

© 2010

Trea

tmen

t Sta

ge

Trea

tmen

t Sta

geC

linic

al T

opic

s

Clin

ical

Top

ics

(Mot

ivat

ion,

Ang

er)

Spe

cial

Pop

s

Spe

cial

Pop

s(C

J, W

omen

)

© 2010“Introduction and self-training” for TCU Mapping

© 2010NO Costs for TCU Manuals

Tools for AssessingTools for Assessing Client Needs Client Needs

and Progress During Treatmentand Progress During Treatment

Stages of TreatmentStages of Treatment

RetentionRetention& Change& Change

Early Recovery

Changes in • Thinking• Acting

Early Early RecoveryRecovery

Changes in Changes in •• ThinkingThinking•• ActingActing

EarlyEngagement• Participation• Therapeutic Relationship

EarlyEarlyEngagementEngagement•• ParticipationParticipation•• Therapeutic Therapeutic RelationshipRelationship

TreatmentReadiness:

• Needs-Risks

• Severity• Motivation

TreatmentTreatmentReadiness:Readiness:

•• NeedsNeeds --RisksRisks

•• SeveritySeverity•• MotivationMotivation

IntakeIntakeInterviewInterview

(eg, ASI/GAIN) (eg, ASI/GAIN)

Short ID & Short ID & BackgroundBackground

Risk InfoRisk Info

Fam/FriendsFam/FriendsNetworksNetworks

MotivationMotivation(from CEST)(from CEST)

PsychologicalPsychological(from CEST)(from CEST)

SocialSocial(from CEST)(from CEST)

Criminal Criminal ThinkingThinking ((CTSCTS))

EngagementEngagement(from CEST)(from CEST)

Fam/FriendsFam/FriendsNetworksNetworks

PsychologicalPsychological(from CEST)(from CEST)

SocialSocial(from CEST)(from CEST)

EngagementEngagement(from CEST)(from CEST)

PsychologicalPsychological(from CEST)(from CEST)

SocialSocial(from CEST)(from CEST)

Criminal Criminal ThinkingThinking ((CTSCTS))

“ShortShortShortShort”(5-7 min.) TCU TCU TCU TCU FormsFormsFormsForms(with

Feedback Charts)

© 2010Mix, Match, Repeat over time

Measures of Measures of Client FunctioningClient 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•Irresponsibility•Power Orientation•Cold Heartedness•Rationalization

© 2010

TCU Short FormsTCU Short Forms for Client Assessmentsfor 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 :1. Physical and Mental Health Status Screen (HLTHFORM) 2. Mental Trauma and PTSD Screen (TRMAFORM) 3. HIV/Hepatitis Risk Assessment (HVHPFORM)4. Family and Friends Assessment (A/Y-FMFRFORM)

C. Client Evaluation of Self and Treatment (CEST) F orms : 1. Treatment Needs and Motivation (MOTFORM) 2. Psychological Functioning (PSYFORM)3. Social Functioning (SOCFORM)4. Treatment Engagement (ENGFORM)

© 2010

These are interrelated, and they CHANGE over timeThese are interrelated, and they CHANGE over time……

50%50%

© 2010

InterpretingInterpreting Client ScoresClient Scores

“ShortShortShortShort”TCU FormsTCU FormsTCU FormsTCU Forms

(with Feedback Charts)

Core Ingredients of Core Ingredients of ““Effective SystemEffective System””

1. Conceptual framework for treatment process

2. Assessments of client functioning (CEST/CTS)

3. Guides (manuals) for targeted interventions:

• Motivation/thinking engagement

• Care planning & behavioral skills training

4. Publications for showing “evidence-base”

5. Implementation principles for organizations

6. Field network of innovation “ready adopters”

© 2010

Innovation ImplementationInnovation Implementation

Stages of Implementation Process

4.Practice Improvement

• Outcomes• Services• Budget

4.4.Practice Practice ImprovementImprovement

•• OutcomesOutcomes•• ServicesServices•• Budget Budget

3.3.ImplementationImplementation•Effectiveness•Feasibility•Sustainability/Cost

1.1.TrainingTraining•Relevance•Accessible•Accredited

2.2.AdoptionAdoptionA. A. DecisionDecision

•Leadership•Quality/Utility•Adaptability B. B. ActionAction

•Capacity•Satisfaction •Resistance

Simpson, 2002; Simpson & Flynn, 2007 (Special Issues of JSAT); Simpson, 2009

Organizational Readiness & Functioning

MotivationMotivation ProgramProgramClimateClimate

StaffStaffAttributesAttributesResourcesResources CostsCosts

© 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 ScalesORC ORC ScalesScales

Organizational Readiness for Change Organizational Readiness for Change (ORC)

Simpson, 2002; Lehman et al, 2002 ; Simpson & Flynn, 2007 (JSAT)

ResourcesResources::•• Offices/StaffingOffices/Staffing

•• TrainingTraining

•• EquipmentEquipment

•• Supervision/Mgmt*Supervision/Mgmt*

StaffStaff

AttributesAttributes::•• GrowthGrowth

•• EfficacyEfficacy

•• InfluenceInfluence

•• AdaptabilityAdaptability

•• Satisfaction*Satisfaction*

MotivationMotivation::

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

“Better organizations”provide “better

services”

ClimateClimate::•• MissionMission

•• CohesionCohesion

•• AutonomyAutonomy

•• Communication Communication

•• StressStress

•• Open to ChangeOpen to Change

© 2010

Ready for Change?Ready for Change?

Climate: Climate: Cohesion of StaffCohesion of Staff(Scale scores range = 10(Scale scores range = 10--50)50)

Similar for Similar for other ORC other ORC measuresmeasures

45 Programs (ITEP/BTEI Projects)

LowestLowest

HighestHighest

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

If LOW, then what can be done -- and how??

© 2010

Diagnostic tools for Organizational Change(Readiness and Capacity)

Organizational Organizational Assessment Assessment

Battery Battery

Structure & Ops(SSO)

Needs/Pressure(ORC)

Resources(ORC)

Staff Attributes(ORC)

Climate(ORC) Identify

Institutional Barriers

Identify Institutional

Barriers

Identify Training Needs

Identify Training Needs

Improve Organizational

Functioning

Improve Organizational

Functioning

Implementing Evidence-based

Practices

Implementing Evidence-based

Practices

TCU Treatment Process ModelTCU Treatment Process Model(Stage(Stage--based assessments & interventions)based assessments & interventions)

Tre

atm

ent P

lann

ing

& D

eliv

ery

Sys

tem

Tre

atm

ent P

lann

ing

& D

eliv

ery

Sys

tem

Based on Simpson, 2004; Simpson & Joe, 2004 (JSAT)

ProgramProgram•• Needs/motivesNeeds/motives•• ResourcesResources•• Staff skillsStaff skills•• ClimateClimate

Drug Use Drug Use & Risks & Risks

Screening Screening

Other Treatments

or Support

Networks

Other Other Treatments Treatments

or or Support Support

NetworksNetworks

Follow-upOutcomes• Drug use• Crime• Social

FollowFollow --upupOutcomesOutcomes•• Drug useDrug use•• CrimeCrime•• Social Social

EngagementEngagement•• ParticipationParticipation•• Therapeutic Therapeutic RelationshipRelationship

RetentionRetentionThresholdThreshold

ChangeChangeChanges in Changes in ----•• ThinkingThinking•• ActingActing

BehavioralInterventions

Social SkillsTraining

ReadinessInterventions

CognitiveInterventions

Recovery SkillsTraining

Detox/Detox/MedsMeds

MotivationMotivation& Induction& Induction

RisksRisksReductionReduction

SupportSupportNetworksNetworks

Trt/CareTrt/CarePlanningPlanning

CM/RewardCM/RewardStrategiesStrategies

CognitiveCognitiveFocusingFocusing

ThinkingThinkingPatternsPatterns

BetterBetterCommComm

LivingLivingSkillsSkills

ProgressProgressMonitoringMonitoring

TransitionTransitionPlanningPlanning

TreatmentReadiness:• Needs• Severity• Motivation

TreatmentTreatmentReadiness:Readiness:•• NeedsNeeds•• SeveritySeverity•• MotivationMotivation

© 2010

SelectedPresentations

IBR HOME PAGE

IBRA National Research Center A National Research Center

for addiction treatment studiesfor addiction treatment studiesin community and correctional settingsin community and correctional settings(over 600 free resource files available)(over 600 free resource files available)

DATOSDATOSDATOS

ProgramProgramProgram

StaffStaffSta ff

Reso urcesResourcesResources

ClimateClimateClimate

PatientPatientPatient

SeveritySeveritySeve rity

Read inessReadinessReadiness

SufficientRetentionSufficientSufficientRetentionRetention

Early Early EngagementEngagem ent

Early Early RecoveryRecovery

PosttreatmentPosttreatment

DrugUse

DrugDrugUseUse

CrimeCrimeCrime

SocialRelations

SocialSocialRe lationsRela tions

ProgramParticipation

ProgramProgramParticipationParticipat ion

TherapeuticRelat ionship

Therapeut icTherapeuticRelationshipRelationship

Behav ioralChange

Behaviora lBehavioralChangeChange

Psycho-SocialChange

PsychoPsycho --SocialSocialChangeChange

EvidenceEvidence --Based Treatment ModelBased Treatment Model

CognitiveCognitiveStrategiesStrategies

BehavioralBehavioralStrategiesStrategies

Social SkillsSocial SkillsT ra iningT raining

F amily &Family &FriendsF riends

SupportiveNetworks

SupportiveSupport iveNetw orksNetworks

Personal Health ServicesPersonal Health Services

Social Support ServicesSocial Support Services

Simpson, 2001 (Addiction)

Pro gramProgramInte rventionsInterventions

ReadinessReadinessTrainingT raining

SUMMARY

TCU Mapping-Enhanced Counseling

TreatmentProcess

CounselingManuals

Corrections-Based

Treatment

NationalEvaluations

OrganizationalReadiness

AssessmentFact Sheets(with norms)

www.ibr.tcu.eduwww.ibr.tcu.edu

Guide for New Visitors

••ManualsManuals

••FormsForms

••Conceptual GuidesConceptual Guides

••PublicationsPublications

EVIDENCE

MANUALS

FORMS

EVIDENCE

ABOUT IBR-TCU

STAFF

PUBLICATIONS

PRESENTATIONS

PROJECTS

NEWSLETTERS

OTHER LINKS

WHAT’S NEW

SITE GUIDES:

© 2010

““VisitorsVisitors””

700+/day700+/day

30 mins30 mins