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Implementing Outpatient Evidence- Based Treatment in a Residential Program

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The implementation of Evidence-Based Treatment (EBT) is increasingly being encouraged by funders and considered best practice by many treatment professionals and accrediting bodies. There are now several EBTs that have been developed, tested and found effective with adolescents who have substance use disorders (Dennis et al., 2004; Springer & Rubin, 2009; Waldron & Turner, 2008). However, most of the EBT manuals that have been developed are designed for outpatient or community-based service delivery. Little has been written about how these treatments might be implemented in existing adolescent residential treatment programs. Moreover, many residential treatment professionals learn about these EBTs at conferences or by reading the literature, but find almost no information to help them tailor these approaches to residential settings.

In the United States, most adolescent residential treatment programs use a modified version of the Therapeutic Community (TC) approach (Morral et al., 2003; Shane et al., 2003). The TC approach was originally developed by recovering individuals for adults, and modified to enhance its applicability for adolescents. Some of the hallmarks of this approach are phases of treatment that participants progress through based on their behavior in treatment, and an expectation that individuals will change in multiple life areas through what is learned from their peers in the community setting. As they progress through treatment phases, individuals earn additional privileges. Conversely, for rule infractions, individuals can lose privileges or receive punishments. Adaptations for adolescents have included: the use of less confrontation; increased emphasis on education; more supervision; and greater involvement of family (Jainchill, 1997). Since TC approaches have been so dominant for residential treatment, most residential programs for adolescents probably employ some of these components and elements of 12 Step approaches, and these sometimes may appear incompatible with EBTs.

It is no small task to change any existing treatment program, and residential treatment systems present some unique challenges. The biggest difference between outpatient treatment and residential programs are the number of hours that youth are involved in services. In residential treatment, staff are responsible for youth 24 hours a day and must constantly monitor them and ensure they are engaged in productive and therapeutic activities for the requisite number of hours each day that are typically prescribed by state licensing. When programs have been in existence for a period of time, staff at all levels develop routines and can be resistant to change. Residential programs, in particular, employ a large number of shift staff who do not have the academic training or experience of licensed clinicians, so management must evaluate appropriate expectations for their skill level and determine how best to train them in new skills. Moreover, it has been documented that clinical staff in the substance use treatment field have high turnover rates, and these rates are probably highest among paraprofessional staff, which contributes to the difficulty of quality staffing for 24-hour programs. Finally, since most EBTs are not going to fully replace an existing approach in a residential treatment program, consideration must be given to how the new EBT will integrate with and enhance the treatment experience.

Adolescent Community Reinforcement Approach
This article describes a case study of the implementation of the Adolescent Community Reinforcement Approach (ACRA) (Godley et al., 2001) in an existing residential program. A-CRA is a treatment that is based on the theory that it is possible to help individuals change their environment to one that is reinforcing without the use of alcohol or other drugs. Therapists are trained to acknowledge that adolescents begin using these substances because they find their use and the associated socialization reinforcing. A-CRA clinicians work to help individuals identify other reinforcers and learn ways to access them. Adolescents also learn to identify antecedent behaviors that precede substance use and other problem behaviors, and how to interrupt these behaviors so that they do not lead to substance use. The approach emphasizes positive interactions during therapy, which is a developmentally more appropriate approach with adolescents than confrontation.

Clinicians are trained to draw from a menu of 17 procedures—many of which behavioral or cognitive behavioral—that can be used based on issues presented during a therapy session (e.g., functional analysis of substance use, problem solving). One of these procedures is a one-page Happiness Scale, which allows participants to indicate their happiness in multiple life areas on a 1 to 10 scale. This exercise leads to another procedure, during which the clinician helps the adolescent develop goals in areas with lower ratings that are specific, stated positively and measurable, and emphasizes that treatment is more about helping these young people with multiple problems find ways to enjoy life, and not just about quitting alcohol and drug use.

Description of the Existing Residential Program. The residential program in which A-CRA implementation took place is a 54-bed program that serves adolescents from Illinois between the ages of 13 to 18. It has been in existence since 1985, and is separated into three units: a female unit and two male units (one of which is a specialized long-term unit for more chronic or behaviorally disordered young men). The program’s approach has evolved with multiple components including: 12 Step groups; skill building groups; individual, group and family counseling; and a token economy system used to reinforce positive behaviors and discourage negative behavior/rule infractions. Like the TC model described above, adolescents progress through different stages of treatment. Adolescents also can attend an onsite school.

Each unit is staffed with clinicians who are either licensed (LCPC or LCSW) or certified by the State of Illinois as alcohol and drug counselors. Clinicians have primary responsibility for the treatment of five to eight individuals and work varied hours, including some evenings. These clinicians provide ongoing assessment of individual needs; individual, group and family therapy; ­discharge planning; and some case management activities, such as maintaining contact with referral sources, probation officers, outpatient counselors and schools. The shift staff are called residential counselors (RCs) and their job duties include: serving meals; making sure that adolescents attend treatment groups on time; checking chore completion; facilitating certain didactic groups; monitoring the adolescents at all times; providing crisis intervention when professional staff are not available; and collecting urine screens. Each unit has a clinical supervisor who hires, trains and provides regular supervision to unit staff. There are additional staff who support the core staff, including curriculum specialists, recreation specialists, nursing staff and a consulting psychiatrist who provides ongoing psychiatric evaluation, consultation and medication management. An associate director coordinates all three units, and a director oversees both residential and outpatient services.

Motivation for Change. The impetus for considering the adoption of a new EBT was quality assurance data that revealed the residential program was experiencing difficulty engaging and retaining young women. For three consecutive years, the young women’s unit had high rates of premature discharges, with many of these individuals returning to juvenile court/detention. During the year before A-CRA implementation, the percentage of young women successfully completing the program decreased from 45 percent for the previous year to 42 percent, and the average length of stay was 35 days (for a program designed as a minimum 90 day). Furthermore, management staff felt the existing treatment approach was focused too much on punitive consequences and not enough on rewarding positive behavior. For example, the token economy system was primarily used to mete out punishments, rather than to shape healthier and positive recovery-oriented behaviors. Since Chest­nut has a research and training division that had led the adaptation and evaluation of A-CRA and was training Center for Substance Abuse Treatment (CSAT)-funded adolescent treatment providers around the country in this approach as part of the Assertive Aftercare and Family Treatment initiative (AAFT; TI-06-007), it was a logical EBT to investigate. Resi­dential treatment staff reviewed the treatment manual (Godley et al., 2001) and the research supporting it (Dennis et al., 2004; Slesnick, Prestopnik, Meyers & Glassman, 2007), and made the decision to pursue staff training in the model for the residential female unit.

Assessing Readiness and Commitment to Change. The decision to adopt a new EBT, because it seems like a good idea, is the first step in a long journey. The next steps are to understand as fully as possible what will be involved during the process of learning and implementing the intervention, and then ­assess program readiness and commitment to adopt the intervention. In order to assess readiness and commitment, there are a number of factors that must be considered, including: how the EBT will be integrated into the existing program; how quickly changes will be implemented; expectations of different types of staff (e.g., primary therapists, residential counselors); what the training process will entail; whether there is an organization level commitment to sustaining the training and implementation effort; how fidelity will be maintained; and how training will be sustained on an ongoing basis.

These questions were discussed during meetings with the program director (M. Kenney), key staff and one of the model developers (S. Godley). The clinical management team decided to add A-CRA to the existing treatment model by increasing the number of individual sessions clinicians provided to adolescents and to train RCs in strategically selected procedures, based on what would be most helpful to them and the adolescents in the residential program. After learning about the rigorous training and certification model (described in Godley, Garner, Smith, Meyers & Godley, in press), the program director made a commitment to adhere to these expectations and implement the model with fidelity to the research-tested manual. Over time, additional plans were made to address sustainability.

Implementation Begins. The decision was made to implement the EBT gradually because experience with another implementation effort had shown that attaining buy-in from strategically chosen opinion leaders helped facilitate the implementation process. Initially, one clinician and the female unit’s clinical supervisor attended training and began the A-CRA dual (clinician and supervisor) certification processes. Clinician certification is based on A-CRA expert reviews of therapy sessions, which are recorded with a digital recorder and uploaded to a web-based system. Experts then listen to the session and rate clinicians on the components of each procedure they attempt to implement and write narrative comments about how to improve their implementation (see Godley et al., in press). The hope was that the first clinician would like the model, training and certification experience, and would then become an internal champion for the model and influence other staff positively. The initial feedback from this clinician was very positive, and she perceived that her clients were responding very well to her use of A-CRA procedures, in short, supporting how management believed A-CRA would enhance ­treatment and providing the confidence to move forward with the rest of the young women’s unit staff. The remaining clinicians were trained and expected to become certified in 19 A-CRA procedures because management felt it was important that participants receive all of these procedures during their treatment episode.

The decision also was made that shift staff or RCs would be expected to become certified in three A-CRA ­procedures that were especially relevant to issues that routinely arose on the residential unit, often in the late evening hours when other staff were not present. These procedures were communication skills, problem solving and anger management. In this way, the RCs were able to help adolescents practice their skills numerous times in real-life situations on the unit. Thus, problem interactions between the young women on the unit or between adolescents and staff often became opportunities for practicing positive life skills, rather than situations in which negative consequences were assigned.

Management staff were instrumental in encouraging both licensed clinicians and RCs to practice procedures with each other and record sessions using procedures with adolescents. Certain staff members (especially those who were not trained with this type of feedback) were reluctant or fearful of recording their work because they were anxious about receiving the narrative feedback and an “evaluative” score of their work. To address this barrier, management staff were liberal with praise for progress and began offering small incentives for staff who recorded sessions. Once staff received their feedback from the expert reviewers and discussed it with their supervisor, the positive way in which feedback was given helped lessen their anxiety. Interestingly, although many staff felt that the clients would be uncomfortable with the digital recording, this has not been the case. In more than two years, there has never been an adolescent in the residential programs who has refused to be recorded.

Implementation Benefits. Overall, interactions between treatment peers and staff have become more positive, and they have a common language to use in certain challenging situations. For example, talking about an “Understanding Statement” (a component of communication skills) or “Cooling down” (a component of anger management) is commonplace. Since the model emphasizes a positive approach; focuses on each individual adolescent’s reinforcers; and encourages the use of praise, adolescents feel good about their time with clinicians and RCs. One example of changes related to in­creasing the availability of positive interaction is that prior to implementing A-CRA, the only attention that adolescents would receive after a urine test was if they tested positive for drugs; and this attention typically came with negative consequences attached. Adolescents are now praised for submitting negative (clean) urine screens (particularly when they return from passes to their home community).

Another benefit is that by incorporating RCs appropriately into this implementation effort, their training has become more systematic and focused to their role, and they have been able to learn important clinical skills. They are now seen more as part of the clinical team, and the adolescents appear more apt to respect their experience, knowledge and role on the unit. An added benefit is that several of the RCs have begun ­certifi­cation in procedures outside of Communication Skills, Anger Manage­ment and Problem Solving. The process has helped identify individuals who demonstrate potential to become clinicians, and it gives them opportunities for continued professional growth. Adolescents are given positive rewards including praise and behavior tokens, which can be ex­changed for privileges like making a phone call, passes to leave the unit, or promotion to new levels. When participating in sessions with the RCs, they will often request to have a session to practice A-CRA related skills. The young women’s unit also has incorporated A-CRA procedures into its level system, identifying specific procedures that are appropriate, considering the level that the adolescent is at in his/her treatment experience. For example, prior to beginning overnight passes to their home environ­ment, they should have p­articipated in Refusal Skills and Relapse Prevention as well as Sobriety Sampling.

Maintaining Model Fidelity. Maintain­ing fidelity is an important aspect to implementing any EBT. To emphasize the importance of attaining certification and maintaining model fidelity, policies have been written regarding these expectations, and job descriptions were re-written accordingly. By doing so, the management staff have demonstrated that competency in A-CRA delivery is just as important as other job duties like completing clinical records. Addition­ally, each month management staff produces and reviews a management report that provides data about where their staff are related to the certification process (e.g., number of digital sessions uploaded to the web tool, number of procedures passed), as well as competence shown during fidelity checks for those already certified. Clinical supervisors work with staff who are reluctant to record, or who are struggling to pass procedures during supervision sessions using a combination of review and role plays. It is important to note that a few staff in place at the beginning of the implementation project have not been able to adapt to the model, and if they could not, then objective criteria (based on reviews of in-session behaviors and progress in the certification process) were used to determine their continued appropriateness in their positions. Finally, quality improvement data suggested that retention on the unit had increased. In the year after implementation, for the first time in three years, the percentage of successful completions increased, from 42 percent in the prior year to 55 percent; and the overall length of stay increased in the year following implementation from 35 to 49 days across all discharge types (As Planned, Against Staff Advice (or AMA) or Administrative Discharge).

Sustainability and Next Steps. Typi­cally, funds are needed to support the training and implementation effort (e.g., training workshop, session ratings, management report production, coaching). Since the residential program was in the same organization as the national trainer, some in-kind services were provided, but these services were not going to be available on an ongoing basis. Since no new funds were available to help with sustaining the model, the implementation team had to be creative in developing mechanisms to sustain the training and certification process. Early on, a decision was made to train an individual who worked the night shift in how to rate the three procedures that RCs were required to learn. This individual had time ­available because adolescents were sleeping during this shift. The unit supervisor also completed the A-CRA clinical supervision process, which requires that an individual demonstrate appropriate A-CRA supervision skills during recorded super­vision sessions and the ability to rate session recordings adequately when ratings are compared to an expert rater. Another aspect of this process is for one of the model developers to help shape an internal training process through iterative reviews of training agendas. This was done and a training team was developed, led by the Clinical Supervisor and the first clinician trained and certified in the model. The director of youth services also became a certified expert rater and took on the tasks of maintaining the certification workbooks (electronic spreadsheet for each staff member that shows ratings for each session and progress in certification), and assigning ratings to internal staff trained to do this. There are now regular trainings for new staff in A-CRA procedures.

After the young women’s unit had been using A-CRA for a full year, management staff began discussing the possibility of bringing the model to the young mens’ units. Once again, the decision was made to implement in phases. Primarily due to the volume of recorded sessions that need to be reviewed during the initial certification process, it was decided to train staff on the shorter term male unit first. Also, staff on the long-term unit had the most concerns that the model would be inconsistent with their behavior management approach. In other words, they felt that A-CRA was too “soft” of an approach for the conduct disordered males. The short-term young men’s unit was trained in a ­similar manner to how the young women’s unit was trained, and the clinicians and the clinical supervisor were certified through combining help from the EBT training center and program resources. The young men’s unit has responded very favorably to the model and is experiencing some of the same success that the young women’s unit has experienced. Plans are now in place to spread the implementation to the long-term male unit.

Recommendations for EBT Imple­mentation in Residential Settings. Fun­ding sources are increasingly requiring treatment programs to use EBTs, and parents are also asking questions about whether programs are using a treatment that has de­mon­strated effectiveness.

As ­resi­dential programs consider implementing EBTs, we suggest the fol­low­ing recommendations:
• Before EBT implementation begins, articulate the goal for implementing the EBT and how success will be measured.
• Anticipate implementation challenges (e.g., staff resistance to change) and how these might be addressed.
• Plan with key staff prior to implementation how an EBT will be integrated with the existing approach and how the existing approach may change. For example, if motivational interviewing was going to be implemented in a program that routinely uses con­frontation and punishment, key staff would discuss how program practices would change to be more congruent with the new approach.
• Educate key staff about the training and competency requirements and ensure there is commitment from the top to fully implement the EBT with fidelity.
• Develop a phased implementation plan to help increase the manage­ability of the implementation process and build on successes.
• Develop multi-level imple­mentation performance indicators and monitor them on a regular basis (e.g., monthly). For example, these can include indicators of clinician progress, supervisor progress and program level progress (e.g., number of competency criteria passed, number of staff achieving competency, whether the supervisor is achieving competency).
• Use creativity in developing a plan to sustain the EBT after initial stages of implementation (e.g., involve shift staff in fidelity assurance work, praise staff for meeting fidelity goals over time).

Acknowledgements: This work was supported by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), CSS SAMHSA contract No. 270-07-0191. The opinions herein are solely those of the authors and do not represent the position of the U.S. Government. The authors would like to acknowledge the staff of Chestnut Health Systems’ Odyssey and Discovery Units, with special thanks given to Neal Hubbard and Kelly Luckey. The authors would also like to acknowledge Joan Hartman for her administrative support and commitment, Mark D. Godley for reviewing a draft of this article, and Stephanie Merkle for editorial assistance.

References

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