Editor’s Note: It is widely recognized that there is an urgent need for communication between the researchers and the practicing clinicians in the addiction field, especially given the growing advocacy of evidence-based treatments. Leaders in both sectors of the addiction field have taken note of this and are encouraging researchers to partner with clinicians to share their scientific findings to improve treatment strategies.

In an effort to disseminate this knowledge that can improve addiction treatment, Counselor, The Magazine for Addiction Professionals has partnered with the Journal of Substance Abuse Treatment, to provide research-based articles that have been adapted to meet the needs and concerns of its audience — addiction treatment providers. The publishers and editors of both Counselor Magazine and JSAT hope that these articles will inspire increased communication between researchers and treatment providers.

Therefore, it is with great pleasure that I bring you the first in a series of articles that represent a collaborative effort between Counselor Magazine and the Journal of Substance Abuse Treatment. In the first article of the series, “A Plan for Planning Treatment,” author Dwayne Simpson, PhD, provides an integrated view of treatment, leading to a conceptual framework for understanding and explaining to clients a broad rationale for their care planning. In the context of describing a model of the process of substance abuse treatment, Dr. Simpson suggests both interventions and instruments for periodic assessment that can be employed to permit clients’ gradual progress toward recovery.

I would like to thank Barry Brown and Thomas McLellan of JSAT, and Herb Niemirow of Elsevier, publisher of JSAT, for their guidance and assistance in bringing these articles to the readers of Counselor Magazine.

Meanwhile, expectations for counselors to follow “evidence-based practices” are escalating. Adoption of new ways of doing things is easier said than done, however, especially in treatment settings where time and economic resources are limited, programmatic priorities are not in clear focus, and requirements for implementing new interventions are rigid.

So what are practitioners to do? For most, this is a concern that goes beyond worries about licensure, certifications, or job security. It is about making optimal use of time and resources to grow as an effective counselor. Given the high stress and burnout rates of staff, pushing science-based treatment advances into practice is tricky. Without clear benefits, adequate resources, and a supportive environment, adoption of new ideas is unlikely to be permanent.

Getting practical
This article is based on findings presented in another article, “A conceptual framework for drug treatment process and outcomes” published in the Journal of Substance Abuse Treatment (Simpson, 2004). More than 300 articles from the scientific literature were reviewed, including studies from psychotherapy and other treatments for mental illness, alcohol abuse, and drug abuse. Major efforts went into organizing findings about therapeutic dynamics across these somewhat insulated research fields. Patterns of similarities were integrated into a conceptual framework, including discrete interlatching components representing steps in the typical journey to recovery. (A companion paper, by Simpson and Joe, 2004, also appeared in the same JSAT issue and presents empirical longitudinal evidence for the framework.)

The treatment puzzle pieces did not all fit together perfectly, of course, but clear and consistent pictures emerged from these studies that seem to offer practical guidelines for planning and managing clinical care. Attention also was given to types of interventions, particularly for substance abuse treatments that were shown to be effective. More importantly, these interventions were reviewed in relation to how they fit within a targeted strategy to initiate and sustain appropriate therapeutic change. Finally, examples of client assessments to measure, monitor, and manage the clinical process were reviewed.

The main applications drawn from the Simpson (2004) article for treatment practitioners are presented below, along with some examples on how they are relevant to practice in the “real world.” They are organized as follows:
1. principles of treatment process and its major dynamics
2. strategic planning to deliver appropriate interventions
3. assessments for monitoring and managing clinical care

Principles of treatment process
Do counselors in general have a comprehensive view of how treatment works, and does it make any difference in the quality of services they provide? In many programs, counselor burnout and turnover rates are high, so new counselor recruits get a lot of “on-the- job” training. Their counseling focus often is reactive — e.g., dealing with client crisis resolution, program compliance, and documentation. Clinical training often emphasizes the intervention “flavor of the day” rather than program needs. Clinical supervisors (sometimes psychologists or psychiatrists) are the ones typically expected to have a broader, often academically-based view of treatment that can help guide care planning.

With mounting evidence that clarity of program mission, as well as efficient staff functioning (cohesion, communication), are related to quality of drug treatment services, it can be argued that establishing common therapeutic foundations is worthwhile (Lehman, Greener, & Simpson, 2002). Towards that end, the Texas Christian University (TCU) Treatment Model (see Figure 1) provides a visual overview of findings presented in detail by Simpson (2004). This is called a “model” rather than “theory” because treatment actions are summarized instead of mere speculation or hypotheses.

Findings from the scientific literature are not surprising, original, or unique. For many experienced counselors, indeed, they are intuitive and generally confirm things they already know. However, putting it all together in a coherent “package” can be useful for thinking and talking about treatment as a process. In particular, the sequential relationships between needs and motivation for treatment, early engagement, early recovery, length of stay in treatment, and post-treatment outcomes are stitched together.

The model specifications began with long-standing findings from large-scale national evaluations and clinical trials that show more time in treatment is related to better outcomes. More specifically, outcome research indicates that therapeutic benefits tend to begin showing up behaviorally (and reliably) only after about three months of treatment. Efforts have intensified in recent years for exploring client attributes and clinical dynamics that are related to retention and subsequent outcomes.

Figure 1 summarizes this work, showing that higher pretreatment levels of client motivation and readiness for treatment (including problem severity) are related to better treatment results. Indicators of treatment progress are represented in three stages. First, clients entering treatment must participate (i.e., show up regularly for scheduled sessions) and begin forming positive therapeutic relationships with the counseling team. These indicators of early engagement are especially important in the first two months after treatment admission, and they are positively related to client motivation and treatment readiness. Second, indicators of early recovery (defined by behavioral and cognitive assessments of client thinking and actions) by month three are directly related to the level of early engagement shown by clients. Third, favorable evidence on early recovery indicators predicts better retention in treatment.

As already noted, this portrayal of recovery steps is hardly novel. However, progress has been made in establishing the evidence base for it. Reliable assessments also are now available for these clinical constructs, including brief scales shown to have practical utility. The most significant implication of having measurable stages of treatment process is that interventions can be strategically planned and evaluated in regard to their efficacy for addressing specific needs and progress of clients.

Strategic planning of interventions
The delivery of treatment is not always matched to the needs of clients. This can be like an auto mechanic working on the carburetor when the problem is in the transmission or power train. Contrary to a “one size fits all” approach, deliberate diagnosis, planning, and delivery of tailored interventions are fundamental to treatment effectiveness. Because of the high frequency of early dropouts and inefficient use of related resources in many programs, vigilance for “front end” stages of treatment is especially crucial. Like links in a chain, the quality of all elements of treatment is important for maintaining its overall integrity and cost effectiveness.

The treatment effectiveness literature generally supports use of motivational enhancement techniques, cognitive strengths-based counseling, behavioral reinforcement therapy, and social support networking approaches that are prominent in the drug counseling field (National Institute on Drug Abuse, 1999). A comprehensive series of similar interventions has been developed and tested as part of the TCU treatment research program (Simpson, 2004; Simpson & Joe, 2004). They were designed with the goal of being explicit about focus and impact on the stages of therapeutic progress described earlier. These brief (e.g., 4-8 sessions) interventions are manual-driven and integrated for mix-and-match applications through a unique cognitive-based counseling technique called node-link mapping. This is part of a treatment system that exemplifies how research can be translated into practice.

Experimental studies of these stage-specific brief interventions demonstrate that treatment induction and readiness training improves motivation and early engagement (e.g., Czuchry & Dansereau, 2005). Behavioral interventions (e.g., contingency management; see Rowan-Szal, Bartholomew, Chatham, & Simpson, 2005) and cognitive techniques (e.g., node-link mapping; see Newbern, Dansereau, Czuchry, & Simpson, 2005) improve treatment engagement indicators — participation and therapeutic relationship — as well as retention. Furthermore, their collective use increases proportionately posttreatment outcome performance (Rowan-Szal et al., 2005).

The TCU treatment manuals and resources listed in Table 1 evolved from this research program and are available for downloading without charge at www.ibr.tcu.edu.

Client assessments for clinical care
One of the ways to monitor client functioning (individually and collectively) is to use the TCU Client Evaluation of Self and Treatment (CEST) assessment developed in conjunction with the TCU Treatment Model. It includes scales for motivation, psychological and social functioning, therapeutic engagement, and social support (Joe, Broome, Rowan-Szal, & Simpson, 2002). When administered at intake and periodically during treatment, the CEST addresses client needs and progress. Repeating CEST assessments over time can be used to evaluate client progress individually or collectively as a measure of program effectiveness.

The 16 scales (see Table 2) contain an average of nine items each (scored on a 5-point Likert scale ranging from strongly disagree to strongly agree), and require about 25 minutes to complete. Joe et al. report that principal components analysis have confirmed the factor structure of the scales; coefficient alpha reliabilities showed they have adequate levels of psychometric internal consistency; and their relationships with selected indicators of client and program functioning document their predictive validities.

The CEST is one of several client and organizational functioning assessments available for downloading without charge from www.ibr.tcu.edu. A scoring guide explains procedures for computing scores for CEST scales (users will find that some items require “reflected” scoring for items with reverse wording, and that a limited number of missing responses is permissible). In essence, the set of item responses (i.e., values of 1 to 5) for each scale are averaged and multiplied by 10, yielding scores that range from 10 to 50 and a midpoint of 30. Higher scores reflect more of the named attribute. They can be plotted graphically in a line chart to define a functioning profile for an individual client. By averaging scale scores across all (or a sample of) respondents from the same treatment program they can be used to
represent group functioning. Interpre-tations of scores are aided by means and norms calculated using previous research based on the CEST assessment.

Figure 2 contains two hypothetical examples of client functioning profiles, plotted on a graph that also contains 33rd and 67th percentile norms. The Client A profile (indicated by circles) is very “middle of the road”; it reflects average scores of each of the scale, ranging from 25 (on depression and on hostility) to 41 (on treatment participation). In general, this profile of client functioning shows highly favorable treatment motivation and engagement scores (all around 40). It also identifies no unusual psychosocial functioning problems when compared to a total of almost 9,000 other drug treatment clients.

On the other hand, the Client B profile (indicated by Xs) was defined hypothetically to reflect a more troubled —and not unusual — treatment challenge. Although the set of psychological scores fall near or just outside the 33 to 67 percentile norms (showing comparatively low self esteem, higher depression and anxiety, and lower decision making and self efficacy), there are other more significant client functioning deviations that would raise counselor concerns. These include the low scores on motivation (i.e., desire for help and treatment readiness) as well as treatment engagement (treatment participation, satisfaction, and rapport). There also are marginal signs of problems with social functioning (hostility and risk taking) and social support. For purposes of illustration, remember that this profile could be scores for an individual client, or it could represent aggregated (averaged) records from all clients in a treatment unit.

Given this situation, the clinical question is “what to do?” From the TCU Treatment Model and associated interventions listed earlier, the initial recommendations might be to attend to
motivation issues and related engagement issues, drawing particularly from the cognitive-based treatment planning interventions. If client session attendance per se was found to be poor, the behavioral (contingency) management modules should be considered. The elevated hostility score likewise suggests that brief intervention for anger management might be appropriate. Finally, the low social support scores point to a need for some social skills interventions (e.g., involving communication and network building). The cognitive planning maps could help prioritize these overall needs, and repeating the CEST assessment would be useful for monitoring client changes in response to these interventions.

Getting programs to adopt “new plans”
Program directors and counselors in some programs may think this makes good sense and should be adopted for practice. As Brown (1995) emphasizes, however, developing and distributing ideas for treatment innovations is but the first step of a complicated process of getting programs to make changes.

As treatment organizations are being pressed to adopt “evidence-based” innovations for improving effectiveness and efficiency, questions about operational structure and functioning are beginning to receive greater attention. A recent paper by Simpson and Dansereau (in press) describes how to conduct an assessment of organization functioning related to “change.”

Treatment programs intend to address poor motivation, cognitive focus, and behavioral discipline of their clients in an effort to solve problems related to drug use. It is interesting that when these programs are themselves faced with making changes in their own “organizational behavior,” many are hampered by dysfunctional characteristics, similar to those commonly reported by their clients.

Organizations progress through systematic steps before new ways of doing things become “normal” (Simpson, 2002). More specifically, exposure to new information and ideas gets processed through several steps before being accepted as practice. First, decisions must be made about adoption — that is, to try out new ideas — based in large part on their satisfactory appeal to staff and leadership, and their philosophical fit with prevailing values about treatment process and recovery. The next step is implementation on a trial basis, which is typically guided and sustained according to ease of use of the innovations, as well as type of feedback and reactions received from clients and staff. The ultimate step of moving from trial use to routine practice of new interventions and procedures depends largely on benefits (compared to costs) that accrue to leadership, staff, and clients, as well as having an effective monitoring and rewards system for recognizing progress.

A crucial dynamic in this change process involves institutional “atmosphere.” Leadership, staff skills and interrelationships, resources, and pressures are major factors that appear to be involved. Like clients moving towards recovery in treatment, organizational motivation and readiness for change raise receptivity of staff to new ideas; but resources must be in place to support decisions about their adoption. Implementation efforts require that appropriate staff skills be available, and a climate of vision, tolerance, and commitment is necessary to make them permanent. Simpson (2002) and Lehman et al. (2002) review evidence that supports these decision-making stages, and summarizes treatment research showing that organizational functioning and client functioning are interrelated.

Conclusion
Hopefully, the “picture” of treatment process in Figure 1 is worth a thousand words. It summarizes key findings from the literature about client recovery steps in treatment, the use of assessments for monitoring this process, and interventions that sustain it (Simpson, 2004). This is not a perfectly linear or rigid representation, but it offers an efficient and accurate description of “how treatment works” in general. For a parsimonious and integrated illustration of using this model systematically for guiding care planning, client assessments, and targeted interventions, resources from a long-range treatment research program at TCU were described. As noted in the original article, however, there are other popular and effective assessments and interventions.

Concerns by treatment directors and counselors about adopting new materials typically revolve around accessibility (including costs); feasibility (including skill and training demands); and credibility (as in “evidence-based”). These are core issues for effectively moving “science to practice.” Namely, materials first must be readily available and affordable — preferably free and downloadable as needed from a “virtual library” on the Internet. They also must be easy to use — preferably manual-driven, scripted, and focused in regard to objectives of sessions. Finally, they must be wrapped in scientific evidence — meaning journal publications that can be cited.

This paper uses the TCU treatment system as an example of what such resources might look like, and they are couched in a heuristic framework that can help understanding treatment as a process. Inasmuch as this model has empirical foundations (i.e., assessments and interventions), there is potential for conceptual and practical applications. At a conceptual level, it can help refine and focus clinical discussions among counseling staff about care planning and client needs (individually and collectively). On the practical side, there are specific resources described above (see www.ibr.tcu.edu) that can be referenced and discussed as options.

Finally, as concluded by Brown and Needle (1994), the value of defining and explaining carefully with clients their “patient roles and responsibilities” in treatment, often has been underestimated. The TCU Treatment Model offers a graphical illustration for counselors to share and discuss with clients at the time of treatment intake as well as periodically over time. In short, it emphasizes that there are “cognitive” steps involving client thinking about entering into — and committing to — a structured process of change. There also are “behavioral” steps that follow, whereby clients learn how to act differently. These client recovery stages, the results from assessments used to monitor progress, and the rationale, for selecting appropriate interventions can be discussed in a cognitive context that helps improve mutual agreements and planning of therapeutic goals. When augmented by visual communication procedures from the TCU tool box of interventions (e.g., Mapping your journey: A treatment guide book), counselors can build therapeutic relationships that are at the core of effective treatment.

Once you have read this article, please visit http://www.ibr.tcu.edu/
info/cmap.html, to view materials discussed in the article.

D. Dwayne Simpson, PhD, is Director of the Institute of Behavioral Research (IBR) and a Professor of Psychology at Texas Christian University in Forth Worth. His work, which has been reported in over 250 publications, focuses on treatment process, transferring research to practice, and the role of organizational functioning in treatment improvement.

Acknowledgements: This work was funded by the National Institute of Drug Abuse (Grant No. DA13093). Its foundations, however, began in 1989 with NIDA funding of our DATAR-1 project (Improving Drug Abuse Treatment for AIDS-Risks Reduction), followed by DATAR-2 (Improving Drug Abuse Treatment Assessments and Resources) and continuing in our current DATAR-3 phase (Transferring Drug Abuse Treatment Assessments and Resources). The interpretations and conclusions, however, do not necessarily represent the position of NIDA or the Department of Health and Human Services. More information (including intervention manuals and data collection instruments that can be downloaded without charge) is available on the Internet at www.ibr.tcu.edu, and electronic mail can be sent to This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
References
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This article is published in Counselor,The Magazine for Addiction Professionals, August 2006, v.7, n.4, pp.20-28.

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