Overview of MET/CBT 5 Adoption

Transcription

1 Overview of MET/CBT 5 Adoption Randolph Muck, M.Ed. Substance Abuse and Mental Health Services Administration Rockville, MD and Michael L. Dennis, Ph.D., Melissa Ives, M.S.W. Chestnut Health Systems, Bloomington, IL Juvenile Treatment Drug Court Orientation Meeting December 13, 2010, Baltimore, MD

2 CYT Cannabis Youth Treatment Trials Motivational Enhanced Treatment/ Cognitive Behavior Therapy (MET/CBT) Sampl, S., & Kadden, R. () University of Connecticut Health Center Farmington, CT USA Treatment Series Volume

3 MET/CBT 5 SAMHSA Assumptions and Mandates At least one counselor and one clinical supervisor will attend training and become certified. Certification requires submission of taped sessions for review and feedback. Certification, if not completed within 6 months, will likely not happen. Management MUST allow time for clinical supervision and participation in conference calls. Clinical Supervisor will work toward supervisor certification and become a rater and trainer at their own site.

4 Background In 1997 the third wave of cannabis use was the largest and youngest cohort to date, double the number of adolescents presenting to publicly funded treatment There were no publicly available manual guided evidenced based practices targeting this population The Cannabis Youth Treatment (CYT) experiments (n=600) were designed to manualize and field test five promising intervention for short term outpatient treatment of adolescent with cannabis (and other) substance use disorders

5 Background Adapted from earlier studies with adult alcohol and cannabis users, Motivational Enhancement Therapy/ Cognitive Behavior Therapy for 5 sessions (MET/CBT5) was the briefest, one of the least expensive, similar in clinical outcomes, and hence one of the most cost-effective approaches evaluated (Dennis et al 2004; French et al 2003). Comparing dosage and theoretical differences in treatment approaches did not yield statistically significant differences in outcomes 12 months postintake, though all were better than treatment as usual.

6 Assumptions of MET Therapist style is a powerful determinant of client motivation and change Change is more likely when the motivation comes from adolescent, rather than being imposed by the therapist, family, school, or court Need to show respect for the client and demonstrate understanding (vs. confrontation) Ambivalence about change is normal Change involves a process

7 Five Strategies of MET. Express Empathy. Develop Discrepancy. Avoid Argumentation. Roll with Resistance. Support Self-Efficacy

8 Assumptions of CBT Substance use is a learned behavior in which use becomes triggered by environmental stimuli, thoughts and feelings and is maintained by reinforcing effects. Individuals who wish to stop or reduce substance use need skills to cope with these triggers, as an alternative to drug and alcohol use. Effective learning of these new coping skills requires repetition and practice with feedback.

9 Assumptions Behind CBT Group Therapy Breaks through isolation Skill deficits are inter-personal in nature and need to be practiced to work Group is realistic yet safe setting in which to practice Provides additional opportunity to recognize problem and its link to consequences Provides therapists the opportunity to observe and provide feedback on inter-personal behavior

10 Effective Adolescent Treatment (EAT) From 2003 to 2008 SAMHSA s Center for Substance Abuse Treatment (CSAT) conducted a phase IV (i.e., post randomization) replication of MET/CBT5 in 36 sites. All sites received standardized training, quality assurance and monitoring on their implementation of MET/CBT5, as well as the collection of data with the Global Appraisal of Individual Needs (GAIN) to facilitate comparison with the original CYT study in terms of implementation and outcome. The objectives of this program were to : 1. Demonstrate that EAT used MET/CBT5 with a more diverse population 2. Replicate the implementation and outcomes of MET/CBT5 3. Identify participant characteristics moderators and intervention mediators that are associated with outcomes

11 EAT More Geographically Diverse WA OR NV CA AK ID AZ UT MT WY CO NM HI ND MN SD WI NE IA IL KS MO OK AR TX MS LA MI IN OH WV VA KY TN NC SC AL GA FL PA NH VT NY ME MA RI CT NJ DE MD DC CYT: 4 Sites Included EAT: 24 Sites Excluded EAT: 12 Sites

12 Sample Selection The Target Population Inclusion Criteria for including cases from the EAT data set were adolescents who: Were assigned to MET/CBT in Outpatient and Reported lifetime abuse or dependence symptoms and Reported substance use in the last 90 days they were in the community and Who were due for follow-up 4702 of 6150 (76%) meet all inclusion criteria, For logistical reasons, an additional 828 (17.6% of 4702) cases were excluded because they did not have a successful follow-up. The final sample size for EAT was 3874 Adolescents with an average time to their last follow-up of 8.0 months. This group was compared using GAIN data to a cohort of 202 Adolescents from CYT that met the same criteria with an average time to their last follow-up of 11.4 months.

13 Demographics Male* 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Race Groups* Age* AA White Hisp Mixed Other CYT MET/CBT5 Outpatient (n=202) EAT MET/CBT5 Outpatient (n=3874) EAT more likely to be Hispanic (Mixed was not an option in CYT) * P<.05

14 Clinical Characteristics Primary Substance Comobidity Delinquency Level* Alcohol Marijuana Amphetamines Cocaine, Opioids, Other None Internalizing Only Both Externalizing Only None Unofficial Arrest/police contact Court/Probation/Parole Correctional Institution EAT Clients less likely to have cannabis as primary substance, similar in their comorbidity, and to have more justice system involvement. CYT MET/CBT5 (n=199) EAT MET/CBT5 (n=2756) *p<.01 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

15 Comparing CYT and EAT In order to compare CYT and EAT, we want to look at both the central tendency (median) and the range. In the next slide we have done this using a Tukey Box Plot like the one shown here. Middle 50% Range Median Criteria In most cases we have scaled the response set relative to the average for MET/CBT5 in CYT

16 Range of Effect Sizes (d) for Change in Days of Abstinence (intake to 12 months) by Site EAT Programs did Better than CYT on average 6 programs completely above CYT Cohen s d CYT Sites (f=0.39) (median within site d=0.29) Source: Dennis, Ives, & Muck, % above CYT median 36 EAT Sites (f=0.21) (median within site d=0.49)

17 Relative Effectiveness of MET/CBT vs. Regular Outpatient change in days Abstinent

18 Reliability of MET/CBT Effectiveness by EAT Site

19 Abstinence Outcomes by Type of Grant Program Adolescent EBP: Specific EBP required, specific assessment tool required (training, supervision, monitoring and certification in both required and overseen by CSAT). Current AAFT (A-CRA/ACC) program. Previous EAT (MET/CBT 5) program. Adolescent involved adolescents not the target population for grantee but some are treated. EBP and assessment tools recommended. Training provided when requested (any grant program that allows treatment of youth). Adolescent focused target of grantee (not program) is adolescents. EBP and assessment tools recommended. Training provided when requested. (e.g., TCE HIV) 19

20 % Change in GPRA Abstinence Measure ((6 month intake)/ intake) 100% 80% 60% 69% 61% Relative Change 40% 20% 21% 13% 0% ACRA/ ACC * GAIN Mandated, ** GAIN Optional Source: SAIS System (GPRA) MET/ CBT5 Include Any Youth Target Youth

21 Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Juvenile Recidivism (29% vs. 40%) Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving MET/CBT combinations and Other manualized CBT Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ACRA) Assertive Continuing Care NOTE: There is generally little or no differences in mean effect size between these brand names Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004

22 Major Predictors of Bigger Effects 1. A strong intervention protocol based on prior evidence 2. Quality assurance to ensure protocol adherence and project implementation 3. Proactive case supervision of individual 4. Triage to focus on the highest severity subgroup

23 Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis Average Practice The more features, the lower the recidivism Source: Adapted from Lipsey, 1997, 2005

24 Implementation is Essential (Reduction in Recidivism) The best is to have a strong program implemented well Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005 The effect of a well implemented weak program is as big as a strong program implemented poorly

25 Limitations Primarily relied on adolescent self report (plus some records on implementation). It would have been useful to have collateral or urine reports. First cut only examined days of abstinence, it is possible that increases in family treatment and mental health services impact other variables. Could have used other ways of adjusting for time in a controlled environment Some individual level variables are highly confounded with site (e.g., being Hispanic). Ideally we should (and will) combine site and individual level predictors in a multi-level model.

26 Conclusions EAT grantees were more diverse geographically, demographically and clinically than in original trial EAT grantees implementation was better than CYT in terms of engagement, similar in dosage, and only slightly less in content Baseline severity was the primary factor explaining differences in the amount of change observed in EAT Engagement, dosage and content were not the major mediator of change environmental variables were in EAT and overall outcomes were similar or better EAT is doing better than general CSAT grantees involving and even targeting youth.

27 Acknowledgements This presentation was supported by the Substance Abuse and Mental Health Services Administration s (SAMHSA) Center for Substance Abuse Treatment (CSAT) under contracts , , , and using data provided by the following CSAT grantees: (CYT: TI-11320, TI-11317, TI-11321, TI-11323, TI-11324, EAT: TI-15413, TI-15415, TI-15421, TI-15433, TI-15438, TI-15446, TI-15447, TI-15458, TI-15461, TI-15466, TI-15467, TI-15469, TI-15475, TI-15478, TI-15479, TI-15481, TI-15483, TI-15485, TI-15486, TI-15489, TI-15511, TI-15514, TI-15524, TI-15527, TI-15545, TI-15562, TI-15577, TI-15586, TI-15670, TI-15671, TI-15672, TI-15674, TI-15677, TI-15678, TI-15682, TI-15686). Any opinions about these data are those of the authors and do not reflect official positions of the government or individual grantees. Thanks to Rod Funk, Mark Lipsey, Barth Riley, Michelle White and Ken Winters for their suggestions. Suggestions, comments, and questions can be sent to Dr. Michael Dennis, Chestnut Health Systems, 720 West Chestnut, Bloomington, IL 61701, mdennis@chestnut.org.