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This Winter 2004-05 issue is also available in Adobe(R) PDF format.   (PDF; 546KB / 6 pages)

Items from this issue: Models of client and systems change  by Dwayne Simpson, IBR Director Simplifying client and program assessments Research Highlights What's new on the Web

Models of client and systems change

The September 2004 publication of my paper on “A conceptual model of drug treatment and outcomes” in the Journal of Substance Abuse Treatment (Vol. 27, No. 2) brings some degree of resolution to the formulation of the TCU Treatment Model.  Evidence presented for this framework transcends the drug treatment research field and addresses a fundamental pattern involved in efforts of individuals to change destructive behaviors.  Similarly, the June 2002 publication of “A conceptual framework for transferring research to practice” in the same journal (Vol. 22, No. 4) addresses issues involved in the change of organizational infrastructure related to service delivery systems as viewed through the TCU Program Change Model.  These models serve as guides, or touch stones, for most of our treatment research at TCU.

This work continues to branch into two parallel and interrelated roads—one for client functioning and the other for organizational functioning.  Evidence supporting their interdependencies is growing, and we are seeing that use of TCU performance-based assessments with clients and within organizations themselves often serves as an impetus of change.  In particular, since our recent computations of norms for profiles of overall “functioning” (based on our data base of 9,000 client and over 2,000 staff assessments), their utility for comparative interpretations has increased sharply.  Treatment programs participating in our research understand the value of these relationships and are integrating the information into their search for solutions for better service delivery.

In this newsletter we highlight these key measures of client and organizational functioning.  Samples and applications of these assessments also are included as a new feature on the IBR Web site (click on Assessment Fact Sheets at www.ibr.tcu.edu).  These brief overviews feature graphs from a diverse sample of programs with average scores and norms highlighted.  Bookmark our Web site for updates on scoring norms as our research continues, along with future refinements of norms for subgroups of clients in specific treatment settings.

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Simplifying client and program assessments

The pressure for substance abuse treatment programs to adopt efficient systems for evaluating the performance of clients as they move through treatment has increased steadily over the past decade.  At the same time, funding sources (and programs themselves) have grown ever more interested in assessments of the treatment setting itself, especially organizational factors that may impact the quality of service delivery and/or the adoption of evidence-based practices. Meeting these needs depends, in part, on collecting the right kind of information and having a comparative framework for interpreting the data.  The TCU Client Evaluation of Self and Treatment (CEST) and the TCU Organizational Readiness for Change (ORC) forms have evolved to meet these demands with established reliabilities and validities based on large national samples of clients and programs. The instruments are most frequently used together to provide agencies with a richer and more comprehensive overview of total program functioning.

Client Evaluation of Self and Treatment (CEST)
Score profiles for the CEST based on client responses provide a snapshot of client needs and performance in the areas of treatment motivation, psychological functioning, social functioning, therapeutic engagement, and social network support.   These profiles have been based on mean scores (10-50 range) for subscales that measure client self-reports of treatment-relevant issues including desire for help, self-esteem, depression, hostility, peer relationships, and satisfaction with counseling staff and services. The recent addition of 25% - 75% norms increases the usability of CEST reports by providing an easy-to-understand interpretative framework.   Figure 1 shows means and norms for CEST score profiles based on 9,000 surveys completed in over 500 treatment programs.   The graphic display makes it easy for programs to plot the averaged scores of their clients onto the graph and make direct comparisons with scores of clients from other programs.   Followed over time, changes in client-level performance and satisfaction with services can be assessed and used to inform treatment planning and program-level decision-making.   A modified version of the CEST for criminal justice populations also is available (CEST-CJ) and includes special scales for assessing the level of criminal thinking used by clients.

Figure 1.   Means and Norms for CEST Scale Profiles.  (Click on figure to view larger version.)

Organizational Readiness for Change (ORC)
The score profiles for the ORC come from both treatment staff and program directors that complete separate versions of the instrument (ORC-S and ORC-D) with scales on program resources, organizational dynamics, and motivational factors.   Treatment staff and directors respond to questions about themselves and their overall perceptions of the state of the organization in areas such as facilities, staffing needs, pressure for change, mission, staff cohesion, and stress.   Like the CEST, ORC profiles include mean scores and 25%-75% norms based on surveys completed by over 2,000 treatment staff and program directors (see Figure 2).   Program units with at least 5 staff members can effectively utilize ORC profiles by plotting average scores onto this chart.   It allows for comparisons with other programs and makes it easy for agencies using the ORC to better identify staff and management issues that fall above or below the midpoint based on aggregated national scores. Modified versions of the ORC have been developed for use in criminal justice treatment settings (ORC-CJ) and for staff in social services agencies that have duties other than the provision of direct client care (ORC-SA).

Figure 2.  Means and Norms for ORC-S Scale Profiles.  (Click on figure to view a larger version.)

Applications in the Field
This past fall, research staff from IBR joined with colleagues from the Gulf Coast Addiction Technology Transfer Center (GCATTC) and representatives of 32 treatment agencies that are members of the Association of Substance Abuse Programs (ASAP) of Texas for a 2-day workshop that centered on interpreting ORC data at the clinic level and making it meaningful.   Staff and directors in all programs operated by the participating agencies completed the ORC prior to the workshop as part of a recent state-level decision requiring Texas programs to begin routine assessments of organizational functioning as part of their funding agreement.   The ORC surveys were administered online to participating programs by the GCATTC and score profiles for each agency were prepared as part of the workshop.

Dr. Dwayne Simpson, together with Dr. Richard Spence and Jody Biscoe of GCATTC, walked participants through the foundational framework of the TCU Treatment and Program Change Models, focusing on organizational factors that influence service delivery.  A “hands-on” segment followed, during which participants used highlighters to plot the scores for their programs and clinics onto charted worksheets with the 25%-75% norms clearly marked. Figure 3 shows an example of a finished profile from a participating program.  The focal point for the remainder of the workshop included an overview of the ATTC publication The Change Book with an emphasis on using ORC score profiles to guide the change process.

Figure 3.  Plotting ORC Scores for a Sample Program.   (Click figure to see larger version.)

The ASAP programs participating in the workshop overwhelmingly rated the experience as beneficial and well worth their time.  The ORC score profiles were viewed as an important vehicle for documenting organizational issues that had been operating “below radar” in many cases.  In other words, the ORC was seen as instrumental in helping highlight problems that many staff had noticed, but had been unable to pinpoint.  GCATTC will conduct follow-up interviews with these ASAP agencies to assess the impact of the workshop on the actual implementation of change strategies at the program level.  In addition, these programs will recruit samples of their clients over the next few months to complete CEST surveys as a sequential step toward better understanding the relationship between client and organizational functioning.

Future Directions
The addition of norm scores to the interpretation guides of the ORC and CEST have greatly enhanced their usefulness in the field.   They also are a “work in progress.”  The challenge now involves addressing some of the limitations of the current score profiles that are based on data from treatment programs with diverse characteristics.  Planned refinements include calculating comparison norms for specific types of treatment programs and client populations (e.g., norms for residential, outpatient, women and children, dual diagnosis, etc.).  The IBR Web site will feature updates on these scoring norms as they become available.

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Research Highlights

Reports in press 

Clinical and systems-level dynamics that should be considered as part of corrections-based substance abuse treatment are addressed in this article that uses a conceptual framework to describe key stages of drug treatment and the relationship between treatment readiness, participation, therapeutic relationships and stabilized recovery among offenders.  The authors suggest that this clinical process should be managed within a broader context that balances security and rehabilitation objectives.  In particular, selection and referral decisions are seen as necessary for efficient applications of treatment resources as well as assessing offender responses to treatment intervention strategies.   Simpson, D., Knight, K., & Dansereau, D. (in press).  Addiction treatment strategies for offenders.   Journal of Community Corrections.

The effectiveness of intervention modules designed to enhance motivation and readiness for treatment was examined in a sample of 146 probationers remanded to substance abuse treatment.  Subjects were randomly assigned to receive either standard treatment or standard treatment enhanced with the motivational modules.  Probationers who received the enhanced interventions reported they were more motivated to be involved in treatment and to reduce risky behaviors (drinking, drug use, sexual activity) at the end of the residential phase of treatment.  The utility of adding “booster” sessions as a way of improving the intervention also is discussed.   Czuchry, M. & Dansereau, D. F. (in press).  Using motivational activities to facilitate treatment involvement and reduce risk.  Journal of Psychoactive Drugs.

Individual drug abuse counseling methods using different types of node-link mapping (a visual representation strategy) were investigated among clients in private methadone maintenance treatment.  Standard counseling, enhanced counseling with “free form” maps, and enhanced counseling with both “free form” and “guide” maps were compared at 6 and 12 months of treatment among clients with low and high levels of behaviors related to attention deficit hyperactivity disorder ADHD.  Findings replicate prior work suggesting the positive impact of using node-link mapping in individual counseling sessions, with particular benefits noted for clients with higher levels of ADHD-type problems.   Newbern, D., Dansereau, D. F. Czuchry, M., & Simpson, D. D. (in press).  Node-link mapping in individual counseling: Differences in session characteristics, psychological status, and treatment retention at six and twelve months for clients with ADHD-related behaviors.  Journal of Psychoactive Drugs.

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What's New on the Web

At the IBR site, http://www.ibr.tcu.edu

Manuals: The IBR Web site has made two additional manuals available for downloading from the site.

• Mapping Your Steps: Twelve Step Guide Maps from the CETOP Project:
  Provides guides and worksheets for helping clients process each of the 12 Steps.
• Team Awareness, from the Drugs in the Workplace Project: Offers a prevention training program for addressing substance abuse in the workplace.

Forms: The new Criminal Thinking Scales assessment and scoring guide are listed with the Correctional TCU Treatment Assessments.

Resource Collections: A new Resource Collection, entitled Assessment Fact Sheets, now provides brief overviews of applications for selected forms, and norms for scale scores allow comparative interpretations.  Forms with fact sheets are the Client Evaluation of Self and Treatment (CEST), the Organizational Readiness for Change (ORC), both featured in this newsletter, and the new Criminal Thinking Scales (CTN).  Assessment Fact Sheets will be updated as needed and new ones added periodically.

Newsletters: A new part of this section will feature Guest Newsletters which highlight IBR.  These guest issues are used with permission and provide an interesting and helpful perspective on IBR research activities from other organizations in the treatment evaluation field.

Graduating soon? 

Check out IBR's Web info on graduate student training opportunities!

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IBR Newsletters

Research 
Summaries on 
Special Topics

Treatment Process
and Outcomes 
(September 2002)
(PDF; 240K/4 pgs)

Organizational Change
(September 2002)
(PDF; 251K/4 pgs)

Treatment Assessment
(September 2002)
(PDF; 270K/4 pgs)

Counseling
Manuals for
Special Interventions
(September 2002)
(PDF; 99K/4 pgs)

Treatment Mapping
(September 2002)
(PDF; 411K/4 pgs)

Treatment Readiness
and Induction
Strategies
(September 2002)
(PDF; 99K/4 pgs)

Correctional
Treatment 
(December 2002)
(PDF; 664K/4 pgs)

Using the TCU Drug Screen (TCUDS) 
(December 2002)
(PDF; 451K/4 pgs)

Contingency
Management
(June 2000)
(PDF; 113K/4 pgs)
  

Research Reports from IBR
(updated newsletter)

Summer 2008
(PDF; 422K/4 pgs)

Spring 2008
(PDF; 181K/4 pgs)

Winter 2006-07
(PDF; 154K/4 pgs)

Fall 2006
(PDF; 290K/4 pgs)

Spring-Summer 2006
(PDF; 202K/4 pgs)

 
Research Roundup (back issues and archives)

Winter 2005-06
HTML (PDF; 518K/6 pgs)

Fall 2005
HTML (PDF; 131K/6 pgs)

Spring-Summer 2005
HTML (PDF; 301K/6 pgs)

Fall-Winter 2004-05
HTML (PDF; 546K/6 pgs)

Summer 2004
HTML (PDF; 121K/4 pgs)

Spring 2004
HTML (PDF; 152K/4 pgs)

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