1 Using Evidence Based Interventions Stephen Brazill, MA, MAC
Dec 25, 2015
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History
Mid 1930s Alcoholics Anonymous
1950s Narcotics Anonymous
The 1970s Hughes Act Research was scarce Knowledge mostly folk science For severe and chronic clients
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History
1980s Drug Free Workplace Act EAPs Inpatient centers grew and prospered
1990s Institute of Medicine report Disconnect between research and
practice Bridging the Gap
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Today
Building the bridge Evidence-based treatments Outpatient treatment Continuum of addictive behaviors
None Mild Moderate Severe
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Now and Future
Ongoing research in academic and community settings
Improving dissemination of innovation
Improving implementation of evidence-based treatments
Client driven Outcome driven Maintenance vs. acute model
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Now and Future Increased intervention via non-
specialist systems Health systems Social systems
The barber shop? Dentist? Religious communities Schools systems
New(er) Delivery systems Internet (meetings, chat room, Second
Life, etc.) Cell phone
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What Does “Work” Mean?
Abstinence? Reduced use? Reduced psychiatric problems? Reduced incarceration? Increased employment? Reduced medical problems? Improved family functioning?
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Levels of Evidence
Randomized clinical trials Quasi-experimental studies Correlational studies Anecdotal case reports, professional
opinion, best practice guidelines developed by consensus
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Problems With Research
Uni-directional Chosen by researchers Controlled settings Specific populations Individual counseling
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Problems With Research
Training (cost, time, follow-through, drift)
Dissemination Less than 50% of programs are using
proven psychosocial interventions 10-17 years for dissemination
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Solutions
Practice to research Clinical Trials Network Outcome research in community
programs Leadership focus on evidence-based
program development and training
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What Research Does For Us
Helps clarify, guide and inform practice
Answers questions Improves outcomes Helps correct for human self-
deception “Addictive personality” Confrontation Victim impact panels
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What Research Does For Us
Dispels myths such as…… Nothing works One approach is superior to another Everything works equally well
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Why Use Evidence-Based Treatments?
Ethical and humanitarian considerations
Public interest and moral obligation Particularly when treatment is
coerced
EBTs Vs. EBP
Evidence Based Treatment Motivational Interviewing
Evidenced Based Practice Allowing mothers to take kids with
them to treatment Hiring empathic counselors
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Miller & Hester 1995: Alcohol
Top Brief intervention Social skills training Motivational enhancement Community reinforcement approach Behavior contracting
Bottom Relaxation training Confrontation Psychotherapy General alcoholism counseling Education
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Miller & Hester 2003: Alcohol (adapted post
COMBINE)Top
Brief intervention Motivational enhancement Community reinforcement approach Self-change manual Opiate Antagonists (Naltrexone) BSCT
Bottom Relaxation training Confrontation Psychotherapy General alcoholism counseling Education
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Miller, Zweben & Johnson 2005
Cognitive-behavioral treatment Community reinforcement approach Motivational interviewing Relapse prevention Social skills training
JSAT 29 (2005)
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Overview of Treatment Methods
Build client motivation, readiness and engage
Cognitive and behavior skills Increasing positive rewards for non-
use Involve family and social networks
Think outside the skin Appropriate medications
A Resource
Understanding Research Concepts: A Guide for Counselors
http://www.danya.com/dlc/courselist.asp
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Important Client Factors
Goals Values Experiences Expectations Strengths Cultural, ethnic and spiritual
background Biology Motivation & readiness
Assessi
ng and
Utilizin
g
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Stages of Change
Precontemplation Contemplation Preparation Action Maintenance
Prochaska, Norcross, DiClemente
Relapse
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Stages of Change
80% of substance abusers are in precontemplation or contemplation
Define success by the movement from one stage to the next
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Predicting Change
Adherence to change efforts Self-efficacy Self-reported motivation Engagement and retention Quality of counseling relationship Client speech
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Influencing Motivation:What Doesn’t Work
Enlightenment Education Insight-oriented persuasion
Confrontation Punishment
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Appears that the counselor to whom one is assigned makes considerably more difference than the specific treatment employed*
*Najavits & Weiss, 1994
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Interpersonal Influence
Referral from your office 2X Call or handwritten note 2X Missed session/letter ½
drop out AA w/member support 100% AC reminder calls/calendar 2X
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Motivation
Is not a static client trait Affected greatly by relationship with
counselor It is interpersonal Measured by client language and
observed behavior
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Change Talk
D = Desire for Change (want, wish, like) A = Ability to Change (could, can) R = Reasons for Change (if……then…..) N = Need for Change (need, have to, got to)
C = Commitment to Change (intention, decision)A = Activation (ready, prepared, willing)T = Taking Steps (tossed out cigarettes)
Motivational Interviewing Is…..
Motivational interviewing is a collaborative, person-centered, form of guiding
to elicit and strengthen motivation for change
Miller & Rollnick (2009)
Motivational Interviewing
Helps increase client change and commitment talk
Helps reduce resistance Helps engage clients Plays well with other treatments
Synergistic effects
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Community Reinforcement Approach
(CRA) Broad spectrum behavioral
treatment Creating ways to reward sober
behavior Positive reinforcement
Utilizing social, recreational, familial and vocational reinforcers
Changing the person’s sources of reinforcement in the community
CRA Components
Job Finding Behavioral marital
therapy Social/leisure
counseling Social club Medication Problem-solving Sober buddy
system
Motivational counseling
Sobriety sampling Drink refusal Immediate
disulfiram administration
Relaxation training
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1 Using/Sobriety 1 2 3 4 5 6 7 8 9 10
2 Job or Educational Progress 1 2 3 4 5 6 7 8 9 10
3 Money Management 1 2 3 4 5 6 7 8 9 10
4 Social Life 1 2 3 4 5 6 7 8 9 10
5 Personal Habits 1 2 3 4 5 6 7 8 9 10
6 Marriage/Family Relationships
1 2 3 4 5 6 7 8 9 10
7 Legal Issues 1 2 3 4 5 6 7 8 9 10
8 Emotional Life 1 2 3 4 5 6 7 8 9 10
9 Communication 1 2 3 4 5 6 7 8 9 10
10 General Happiness 1 2 3 4 5 6 7 8 9 10
Completely Completely Happy Unhappy
Happiness Scale
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Systemic View For every individual with an alcohol
problems, 5 others suffer directly Violence & verbal aggression Unpredictable & embarrassing
behavior Stealing from family Depressed mood, lowered self-
confidence Physical complaints
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Motivation Individuals with substance abuse
problems often report that their decision to enter treatment was prompted by direct influence of CSOs or CSOs acting in concert with others
Success rates for treatment entry when CSOs are directed by professionals:
24% to 86%
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Community Reinforcement and
Family Training (CRAFT) Outgrowth of CRA Assumes that CSOs can play a
powerful role in effecting change Does not assume that CSOs are
responsible for use’s behavior CSOs can benefit from assistance in
learning to take better care of themselves
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Unique Components
Emphasis on safety issues Reliance on functional analysis Identifying and utilizing reinforcers
for both the drinker and CSO Emphasis on personal lifestyle
changes Skills training from CRA
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The Other Benefits
CRAFT-trained CSO functioning from baseline to 3 months showed decreased: anger anxiety depression
Regardless of whether or not the substance user had entered treatment
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CRAFT Procedures
Domestic violence precautions Functional analysis Communication training Use of positive reinforcement Time out from positive
reinforcement
Natural consequences for using Reinforcers for the CSO Suggestion of treatment Rapid intake procedures
Promoting Awareness of Motivational Incentives
Seven Principles Target behavior Choice of target population Choice of reinforcer Incentive magnitude Frequency of incentive distribution Timing of the incentive: Duration of the intervention
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What Do You Get…..
When you take an effective
intervention and implement it in an ineffective way?
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Stages of Implementation
Exploration and adoption Program installation Initial implementation Full operation Innovation Sustainability
Implementation Research: A Synthesis of the Literature
Fixsen, et. al. 68
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Considerations
Provider, agency or system culture and readiness
Buy-in on multiple levels Delivery systems (in-person, manual-
driven, etc.) Staff selection Training design and systems Follow through Supervision, mentoring and
coaching
Big Picture View
Rethinking Substance Abuse: What the Science Shows and What We Should Do About It
William R. Miller and Kathleen M. CarrollGuilford Press 2006
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EBTs
http://www.nrepp.samhsa.gov/index.asp
http://www.drugabuse.gov/blending/
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Implementation
http://www.fpg.unc.edu/~nirn/resources/detail.cfm?resourceID=31
Fixsen, et. al.
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Summary
Anything goes is gone No superior approach for all
individuals Variety of approaches work Different people respond to different
approaches Therapeutic relationship is of GREAT
importance Client goals, values, experiences and
cultural background are important75
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Summary
Treatment programs should offer a variety of evidence-based treatments
Staff should receive training in evidence-based treatments and their work should be observed
Programs need to measure their outcomes
Effective implementation is vital and often overlooked in the process of putting EBTs into practice
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What Really Matters…..
Its is not the amount or setting of treatment
as much as the method of treatment who provides it and how they relate
From W.R. Miller: “Motivation for Change: 25 Years of Unexpected Findings and Their Implications for Treating Addictions”