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This Fall 2005 issue is also available in Adobe(R) PDF format.   (PDF; 131KB / 6 pages)

Items from this issue: Improving treatment in the "real world" Transferring useful assessments Interventions for the real world Research Highlights What's New on the Web

Improving treatment in the "real world"

by Dwayne Simpson, IBR Director

“User friendly” resources must satisfy at multiple levels — that is, the client, counselor, and organization must all find them useful.

Efforts to bridge the science-to-services gap run risks of falling short on both ends.  By customizing a clinical protocol to accommodate what the field demands, its impact may be diminished.   And even after “tweaking,” the protocol may still be a poor match, or too complicated or expensive to sustain in practice. But this is the crux of moving science to service.   Treatment developers, trainers, and evaluators often allow concerns about reliability, fidelity, and clinical controls to nudge aside adequate attention to implementation barriers.   “User friendly” resources must satisfy at multiple levels—that is, the client, counselor, and organization must all find them useful.

The IBR currently operates four inter-connected grants with NIDA funding.   Through these projects we have worked with staff at hundreds of community-based and correctional drug treatment programs located throughout the U.S. and abroad.   Most of these programs are seeking help.   Their major needs include finding better assessments of client progress and their own organizational functioning, and identifying more effective means for service delivery.   Not a surprise.   They also have an interest in utilizing treatment resources that are not only “evidence-based,” but also feasible and sustainable for their clients and programs.   Again, not a surprise.

In this issue of Research Roundup we provide an overview of our “work in progress” toward meeting these ends on several fronts.   Our long-running DATAR Project continues working both nationally and internationally on science-to-services transfer in the area of client and organizational assessments and dissemination of targeted brief interventions.   Large-scale assessments of our country’s criminal justice-based treatment system continue to evolve as part of the CJ-DATS Project, while the TCOM Project has completed its first round of data collection across the country, developing and testing an easy-to-use feedback system that provides client, organizational, and cost-monitoring information for program improvement.   The CETOP Project is fine-tuning new cognitive interventions that focus on treatment planning, engagement, and monitoring applications using node-link mapping and targeted guide maps.   Perhaps to many observers these sequential efforts to spearhead enhancements in publicly-funded treatment systems may seem modest.   But this is the typical road to change.   And as the British statesman Benjamin Disraeli once noted: “The secret of success is constancy to purpose.”  n

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Transferring useful assessments

The real world of drug abuse treatment has changed dramatically since the days of IBR’s pioneering DARP studies (Drug Abuse Reporting Program; summaries available online). When the original DARP data were collected, treatment in the real world was focused on opiate dependence, with a smattering of therapeutic communities and medical detox centers. Funding streams were matter-of-fact, and the counseling interventions used were either “one size fits all” or widely eclectic.

In the decades since DARP, the country has witnessed ongoing changes in the design and delivery of treatment services. From the 28-day craze to the growing emphasis on criminal justice-based treatment, from TC hot seats to motivational interviewing, from focus on inpatient to focus on outpatient—the real world of treatment services has never been a static entity. Across the U.S. today, treatment programs continue to differ in terms of size, focus, philosophy, and types of services offered. Amid this whirl, the average program faces new real world challenges involving the interface of organizational resources, program functioning, and demands for the effective monitoring of clients as they move through treatment.

Transferring useful assessments Tools for the Cause
As many treatment programs have come to realize, gathering data on staff perceptions or client progress is a fairly matter-of-fact process. But making sense of that information is a different story.

The TCU Core Assessments, centered on the Client Evaluation of Self and Treatment (CEST) and Organizational Readiness for Change (ORC) instruments are being studied across all IBR research projects to guide programs in this process. For example, cumulative data from over 1,700 clients and 500 staff in some 100 programs across the country have been gathered as part of IBR’s DATAR (Transferring Drug Abuse Treatment Assessments and Resources) Project, allowing scientists to refine score profiles for both the ORC and CEST. Score profiles for the CEST have been enhanced to include both 25%-75% and 33% - 67% percentile norms, broken out by gender. These score profiles for CEST scales, including mean scores, are presented graphically for easy reading (see Figure 1).

Figure 1.   Means and Norms for CEST Scale Profiles.

Programs that routinely use the CEST can use these charts to plot their own scores and make comparisons with clients in other programs. By re-administering the CEST over time, client changes can be effectively assessed for planning and management. Score profiles for the ORC include 25%-75% percentile norms and are presented graphically like the CEST scores. Programs using the ORC can plot their staff scores for comparison with staff from other programs.

The ORC and CEST are frequently used together to assess overall program functioning and have been found to be an effective tool for monitoring progress and change over time. Charts for CEST and ORC norms are updated periodically on our web site, as new data are collected, to increase their usefulness as an interpretive framework for individual and program level monitoring.

Looking across Populations
The sturdiness of the CEST assessment in applications with diverse clinical populations is demonstrated in a recent study carried out as part of the CJ-DATS Project (Criminal Justice Drug Abuse Treatment Studies). CJ-DATS is a five-year cooperative funded by NIDA to investigate criminal justice treatment systems in the U.S. and to recommend improvements for service delivery. Toward these ends, IBR has spearheaded the Performance Indicators for Corrections (PIC) study in collaboration with the University of Kentucky, National Development and Research Institutes, University of Delaware, and University of California, Los Angeles.

For this study, a cross-sectional sample of 3,266 offenders from 26 prison and community-based correctional treatment programs completed the CJ-CEST (a version of the standard CEST with minor changes for relevance in criminal justice settings, such as replacing the word “client” with “offender”). The CJ-CEST features a trailer with extra scales to assess dimensions of criminal thinking among offender populations (the TCU Criminal Thinking Scales; CTS). Findings support good client and program-level internal consistency, as well as very good test-retest reliability for the CJ-CEST and the CTS. The instruments also demonstrated good measurement sensitivity across different programs, including differentiations between male and female programs (see Figure 2).

Figure 2.  Percentile Norms for TCU Criminal Thinking Scale profiles, by gender.

In addition, significant interrelationships were found between the basic CEST scales and the criminal thinking scales, such that higher levels of criminal thinking were generally associated with lower motivation for treatment, poorer psychosocial function, and lower engagement in treatment. “Assessment Fact Sheets” for the CJ-CEST and the TCU CTS, showing percentiles and gender variations, are available at www.ibr.tcu.edu.

Monitoring Outpatient Program Change
In considering a focus of study for the Treatment Costs and Organizational Monitoring (TCOM) Project, IBR researchers decided to concentrate on gathering data from outpatient treatment providers. In today’s real world, outpatient treatment, whether delivered as intensive services or supportive aftercare, accounts for a majority of treatment slots across the country yet remains understudied from an organizational and service delivery perspective.

To date, TCOM has collected data from staff and clients in 115 outpatient, drug free programs in four U.S. regions (Southeast, Gulf Coast, Great Lakes, and Northwest).   Early studies have examined regional differences in program structure, organizational climate, program resources, and client engagement using special versions of the ORC and CEST surveys, along with in-depth questionnaires about program makeup and operations.   Analyses have identified some minor regional differences in staff perceptions of program resources and organizational climate, and client engagement in treatment.   However, more significant regional differences were found among measures of program structure.   These differences appear to reflect the variations in outpatient services across the country in terms of such factors as the program’s affiliation with a parent organization, national accreditation, client demographics, census, primary drug problem, and services offered.   For example, Figure 3 shows regional differences in types of client services offered by outpatient programs.   Future TCOM studies will focus on interrelationships among program structure, climate, resources, and client factors to further explore the foundation upon which treatment process and organizational change occur. 

Figure 3.   Variations in outpatient services available across four regions of the US.

In the meantime, TCOM researchers continue to perfect the most useful way to provide programs with feedback based on cost and organizational and client assessments.   Reports from the field suggest the team is headed in the right direction.   For example, a medium-sized treatment agency participating in the data collection recently used early feedback reports on clients and staff to draft a detailed executive report for internal use within the organization.   Data from its adult outpatient programs allowed for site and agency-wide comparisons, as well as comparisons with regional averages in areas of client and organizational functioning.   The report is being used to help inform program planning, training, and resource considerations, and the agency director is eagerly awaiting future feedback on costs and cost monitoring for his programs.  n

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Interventions for the real world

Interventions for the real world: "Mapping the Journey"
Monitoring clients as they move through treatment is another demand of today’s real world.   Substance abuse treatment counselors face the difficult task of maintaining focus and forward progress as they guide clients through the development and enactment of treatment plans.   Distractions, nonproductive tangents, memory lapses, and defensiveness place a large cognitive burden on both counselor and client.   Although clinical notes and formal treatment plans address these issues, counselors express the need for additional cognitive “aides” to help with the process.

The CETOP (Cognitive Enhancements for Treatment Outcomes Project) team have recently developed and tested an integrated set of maps to guide the counseling process while helping both the counselor and client keep a record of plans and commitments.   These fill-in-the-box maps can be used flexibly in tailoring treatment to clients’ unique needs and preferences.   The manual, “Mapping the Journey: A Treatment Guide Book” presents an overview of mapping-based interventions and provides mapping guides for helping clients explore themselves and their personal characteristics, their social functioning, ways to make decisions and cope with problems, and ways to manage relapse.   In addition, there are general planning and progress monitoring maps to help clients set goals and understand their progress.

Studies in England
Elements from “Mapping the Journey” and other node-link mapping applications will form the centerpiece of a series of pilot studies in the planning stage for the northwestern area of England.   A planning group from the NTA (National Treatment Agency) recently spent a week with IBR staff to design the content of a brief intervention using mapping and materials from other TCU Brief Interventions. The planned intervention will target increasing engagement and retention in substance abuse treatment programs and will include elements to help clients address thinking patterns and other cognitive distortions that can lead to relapse. This pilot intervention will be introduced by three national treatment services providers in Manchester and surrounding areas, with an estimated 23 programs participating. In addition, as part of the DATAR Project, CEST and ORC data will be collected from clients and staff in participating U. K. programs to monitor baseline functioning and changes associated with staff training and implementation of the new intervention. Upcoming issues of this newsletter will have more detail on our international research as it unfolds.  Copies of “Mapping the Journey” and other TCU Brief Interventions are available at www.ibr.tcu.edu for free download. n

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Research Highlights

Reports in press

Actuarial measures of criminal history are often used in assessing risk of recidivism among offenders.   However, these measures often do not address changes in risk as a result of treatment.   In a study of the TCU Criminal Thinking Scales (TCU CTS), a brief, self-administered instrument that assesses thinking patterns associated with criminal conduct, support was found for the instrument’s basic psychometric properties.   The instrument may have applications as a brief, reliable assessment of the degree to which criminal thinking patterns are endorsed by offenders.   The authors discuss applications of the assessment in determinations of offender progress and risk of recidivism.   Knight, K., Garner, B., Simpson, D., Morey, J., & Flynn, P.   An Assessment for Criminal Thinking.   In Press: Crime and Delinquency. n

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What's New on the Web

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

Science to Services Transfer:
• Brief Interventions from the TCU Treatment System include a series of targeted materials designed particularly for counselors and group facilitators working in substance abuse treatment programs.  The collection of manuals contains focused, easily accessible, and brief strategies for engaging clients in discussions and activities on important recovery topics (social networks, anger, mapping). A Brief Intervention, focusing on contingency management (CM), is the most recent addition to this collection.
• TCU Client Evaluation of Self and Treatment (CEST) Scales now include 25-75 and 33-67 percentile scores for clients (as well as for gender subgroups).

Cognitive Interventions: 
• New set of guides for Mapping the Journey now available for treatment planning and monitoring.
• News article reports on "Downward Spiral" game.

Criminal Justice Treatments:
• The Criminal Thinking Scales assessment and scoring guide are listed with the Correctional TCU Treatment Assessments.
  

At the DATOS site, http://www.datos. org

Publications:  The remaining "in press" publications are now in print, bringing the total number of DATOS publications to over 80.  n

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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
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Spring-Summer 2006
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Research Roundup (back issues and archives)

Winter 2005-06
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Fall 2005
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Spring-Summer 2005
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Fall-Winter 2004-05
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Spring 2004
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