BEING INFLUENCED BY THE EVIDENCE. By Mark Sanders, LCSW, CADC. Fifty percent of chemically dependent clients leave treatment prematurely.

Transcription

1 BEING INFLUENCED BY THE EVIDENCE By Mark Sanders, LCSW, CADC Fifty percent of chemically dependent clients leave treatment prematurely. Fifteen percent are administratively discharged, and the great majority of the rest who relapse do so within the first ninety days of leaving treatment (GLATTC Bulletin, 2005). With these high relapse rates, from the perspective of the federal government (who provides funding to single-state agencies), clearly a treatment paradigm shift is needed. Thus, the movement toward evidence-based practices (Steenrod, 2004). The challenge is the fact that evidence-based practices are difficult to implement for myriad reasons, including: 1. Cost In order to prove fidelity to a model, agencies need to be fortunate enough to receive a large research grant, have a university affiliation, hire research teams to formulate questions, decide the nature of the studies, i.e., double blind, randomized, etc., conduct the trials, make comparisons with control groups, analyze data, and hire utilization review teams (Miller, Zweben, & Johnson, 2005). This is costly! 2. Locating clients With relapse rates being extremely high, many chemically dependent clients are difficult to locate for the purpose of studying results, for reasons ranging from cell phone disconnections, evictions, arrests, homelessness, spontaneous relocations, and geographical cures. 3. Limited direct observation Many supervisors report that they rarely have the opportunity to directly observe counselors working with clients. It is

2 2 difficult to implement an evidence-based practice without direct observation and feedback from supervisors (Emmelkamp & Vedel, 2006). 4. Evidence-based practices vs. reality Most evidence-based practices are individualized approaches (Emmelkamp & Vedel, 2006). Addictions counselors do a great deal of their work in groups. This makes it difficult to utilize evidence-based practices. 5. Natural resistance to change There are counselors who have utilized their clinical approaches for so many years that they could do their work blindfolded. New approaches can be threatening to their comfort level, causing them to resist adopting new ones (Diamond, 1996). 6. Expert approach to implementation Many organizations introduce evidence-based practices by bringing in experts to teach the models to counselors. This is often met with resistance, as some counselors feel that the experts may not live in the real world (Miller, Zweben, & Johnson, 2005; Diamond, 1996). 7. Ignoring grief As organizations move toward evidence-based practices, counselors will naturally have grief reactions. Ignoring this grief can lead to anger and resistance to adopting new approaches (Diamond, 1996). 8. Lack of buy-in from the top There are agencies that attempt to implement evidence-based practices by sending counselors to training without identifying the strategies they will use at the organizational level to ensure that information gained in training will be adopted. Training is not

3 3 enough to ensure adoption; there needs to be buy-in from the top of the organization as well (Miller, Zweben, & Johnson, 2005). BEING INFLUENCED BY THE EVIDENCE While evidence-based practices are difficult to administer, it is possible for counselors to be influenced by the evidence. Suggestions include: 1. Listen more than you talk. The research from many evidence-based practices indicates that there is a relationship between increased verbalization among clients and outcomes, specifically, outcomes are better when the client talks more than the therapist (Miller & Rollnick, 2002; Emmelkamp & Vedel, 2006; Small, 1990). 2. Invite solutions from clients and partner with them. Clients feel a greater satisfaction in counseling when there is a partnership between them and their counselors. This will increase the chances that they will return to future sessions (Miller & Rollnick, 2002; Hubble, Duncan, & Miller, 1999). 3. Minimize confrontation. While heavy confrontation is an important part of the addictions field s historic path, studies reveal that heavy confrontation increases client dropout rates. Other studies indicate that for some clients the more heavily they are confronted the more heavily they drink (Miller & Rollnick, 2002). 4. Spend time in the beginning engaging your client in treatment. Research reveals that client engagement may be a more important determinant of client outcomes than the specific evidence-based practice that is used (Hubble, Duncan, & Miller, 1999).

4 4 5. Increase individual counseling sessions. As a field, we have historically done a great deal of group therapy, as it is time and cost effective. As stated earlier, most evidence-based practices are individualized approaches. 6. Work with families. Studies show that various types of family therapy increase recovery rates, including family systems therapy, structural family therapy, network therapy, behavioral couples therapy, etc. (SAMHSA, TIP 39, 2004; Emmelkamp & Vedel, 2006). 7. Work with Couples. Behavioral couples therapy has proven to increase client attendance in continuous care, reduce the length of relapses, and increase recovery rates (SAMHSA, TIP 39, 2004; Emmelkamp & Vedel, 2006). 8. Provide ninety days of continuous recovery support, as most relapses occur in this window (White, Kurtz, & Sanders, 2005; GLATTC Bulletin 2005). 9. Make assertive linkages into 12-step and other communities of recovery. Handing clients a list of 12-step meetings and simply encouraging them to go is not nearly as effective as assertively linking them into the program, i.e., educating them about the 12-step program before they attend, utilizing volunteer escorts, suggesting tasks to do at the meetings, etc. (Nowinsky, 2004; Nowinsky, 1992). There are also ways in which managers and supervisors can help counselors be influenced by evidence-based practices. These include:

5 5 1. Creation of a transitional space These are meetings in which counselors are able to talk, on an emotional level expressing fear, doubt, anger, etc. about movement away from the old way of doing business toward evidence-based practices. In this transitional space it may also be helpful for counselors to have the opportunity to discuss what they will miss as the agency transitions toward evidence-based practices what they are losing and what they stand to gain (Diamond, 1996). 2. Allowing counselor input Consider allowing those required to utilize the evidence-based practice to have a voice in selecting the model. This is often helpful in reducing resistance (Diamond, 1996). 3. Direct observation In the midst of a busy schedule, it is also helpful for supervisors to take time periodically to observe counselors working with clients and give feedback based upon how their approaches are influenced by evidence-based practices. 4. Shadowing - A cost effective method of giving counselors feedback about their clinical approaches is to periodically hire consultants who are experts in evidence-based practices to spend a day with counselors as they work with clients and give them feedback on the spot about their fidelity to the model. In many ways, this approach can be less threatening to counselors than supervisor observations, since the consultant does not have the power to influence their annual reviews but simply to help them with the implementation of evidence-based practices.

6 6 REFERENCES Diamond, M. Innovation and Diffusion of Technology: A Human Process (Fall, 1996) Consulting Psychology: Practice and Research, Vol. 48(4), pp Emmelkamp, Paul M.G. & Vedel, Ellen. (2006) Evidence-based Treatment for Alcohol and Drug Abuse. New York: Routledge GLATTC Bulletin, September 2005, Chicago, IL Hubble, Mark, Duncan, Barry L., & Miller, Scott (Eds.) (1999) The Heart and Soul of Change: What Works in Therapy. Washington, DC: American Psychological Association Miller, W., Zweben, J., & Johnson, W. (2005) Evidence-based Treatment: Why, What, Where, When, and How? Journal of Substance Abuse Treatment, Vol. 29. Miller, William & Rollinck, Stephen (2002) Motivational Interviewing. New York: Guilford Press Nowinsky, J. et al (2004) Facilitating 12-Step Recovery from Substance Abuse and Addiction. In Treating Abuse: Theory and Technique, New York: Guilford Press, pp Nowinsky, J. et al (1992) Twelve-step Facilitation Therapy Manual DHHS Public No. ADM , Rockville, MD: NIAAA Small, Jacquelyn (1990) Becoming Naturally Therapeutic: A Return To the True Essence of Helping (Revised) New York: Bantam Press Steenrod, Shelly A. (2004) The Use of Evidence-based Practices in Substance

7 7 Abuse Treatment Programs. Journal of Evidence-based Social Work, Vol. 1(4), pp Substance Abuse Treatment & Family Therapy: A Treatment Improvement Protocol (TIP 39), U.S. Department of Health and Human Services White, William & Kurtz, Ernest (2006) Recovery: Linking Addiction Treatment and Communities of Recovery. Pittsburgh, PA: ATTC White, William, Kurtz, Ernest, & Sanders, Mark (2005) Recovery Management. Chicago, IL: Great Lakes ATTC ABOUT THE AUTHOR Mark Sanders, LCSW, CADC, is a member of the faculty of the Addictions Studies Program at Governors State University. He is CEO of On The Mark Consulting, an international addictions training and consulting organization. He can be reached at onthemark25@aol.com.