Loosening the Grip: a handbook of Alcohol Information 9th

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Chapter 14 Odds 'n' Ends

Issues of the Profession

Arfken CL, Agius E, Dickson MW. Clinicians’ information sources for new substance abuse treatment. Addictive Behaviors 30(8): 1592–1596, 2005. (8 refs.)

Little is known about clinicians' information sources for new treatments or ways to improve dissemination of that information. We analyzed 163 clinicians' responses to a checklist of where and how frequently they obtain information on new treatment approaches. They reported at least yearly use of a median of four cosmopolite categories (e.g., journals or books, Internet) and a median of three local categories (e.g., co-workers, personal experience) with interpersonal contact with co-workers (89%) and seminars/conferences (86%) being the most frequently endorsed responses for at least yearly use. In response to the hypothetical scenario of receiving monthly e-mail summaries of journal articles, 59% of the clinicians rated the strategy as "very helpful". If continuing education credits were offered, more clinicians (from 50-80%) would read the relevant articles. Information dissemination may improve with expanded Internet access at programs and short e-mailed summaries carrying links to full articles coupled with the incentive of earning continuing education credits. Copyright 2005, Elsevier Science Ltd.

Baer JS, Rosengren DB, Dunn CW, Wells EA, Ogle RL, Hartzler B. An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians. Drug and Alcohol Dependence 73(1): 99–106, 2004. (33 refs.)

We evaluated a 2-day training workshop on motivational interviewing (MI) for addiction and mental health clinicians (n=22). Clinicians completed the helpful responses questionnaire (HRQ) and taped interactions with a standardized patient (SP). Independent, blinded coders rated the tapes using the motivational interviewing skills code (MISC). Post-training assessment showed significant increase on the HRQ and two of four MISC summary scores for SP interviews. At 2-month follow-up, means of the HRQ and two MISC summary scores remained higher than baseline, but declined from post-training. Some MI skills improved to a greater degree than others, and a subset of clinicians (>40%) showed continued improvement at follow-up. Results were consistent across interviews with different SPs, supporting the use of this assessment method. Findings highlight the need for additional research on the use of standardized patients, alternative assessment techniques, and effective methods of technology transfer for MI skill acquisition and retention. Copyright 2004, Elsevier Science

Blume SB. Confidentiality of Patient Records in Alcoholism and Drug Treatment Programs. New York: American Medical Society on Alcoholism and Other Drug Dependencies and National Council on Alcoholism, 1987.

Note: This pamphlet reviews the 1987 revisions of the federal regulations governing the confidentiality of alcohol and other drug abuse patient records. It addresses the records covered by the regulations; the types of communications covered; written informed consent; the application of consent to situations involving minors, incompetent persons, and deceased persons; the types of information to be released with consent; and the security of records.

Center for Substance Abuse Treatment, Addiction Technology Transfer Centers Curriculum Committee, Deitch DA. Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice (TAP) Series 21. Rockville, MD: CSAT, 1997. (Chapter refs.)

This volume identifies the knowledge, skills, and competencies that are required to master the clinical competencies that have been set forth by the a Curriculum Committee of the Addiction Technology Transfer Center Program. (This program is a CSAT sponsored initiative to promote the education and training of human service professionals and addictions counselors). This report is organized into three sections, with multiple parts. The first section sets forth the knowledge and attitudes that underlie competent practices for addiction personnel. The second Section presented in an outline format sets forth nine clinical practice areas: evaluation; treatment planning; referral; service coordination; counseling; client, family, and community education; documentation; professional and ethical issues. For each of these clinical practice a set of accompanying clinical competencies are defined. Copyright 1998, Project Cork

Chiauzzi EJ, Liljegren S. Taboo topics in addiction treatment: An empirical review of clinical folklore (review). Journal of Substance Abuse Treatment 10(3): 303–316, 1993. (151 refs)

This article reviews 11 taboo topics, that is, research findings that question traditional assumptions and teachings of addiction treatment. These topics include: (1) the lack of empirical support for the Minnesota Model; (2) questions about the necessity of Alcoholics Anonymous for maintaining abstinence; (3) the existence of spontaneous remission; (4) the detrimental aspects of labeling; (5) the value of addicted individuals' self-reports; (6) the lack of empirical support for the addictive personality concept; (7) cue exposure as an underutilized intervention; (8) the interactional nature of motivation; (9) the value of smoking cessation in early recovery; (10) the overuse of the addiction concept; and (11) the lack of empirical support for the disease concept of codependency. Misconceptions arise due to the lack of communication between disciplines and the experiential bias of current addiction treatment modalities. Emphasis is placed upon the importance of empiricism in order to advance the addiction field beyond faith and supposition. Copyright 1993, Pergamon Press

Forman RF, Bovasso G, Woody G. Staff beliefs about addiction treatment. Journal of Substance Abuse Treatment 21(1): 1–9, 2001. (34 refs.)

In 1999, the National Institute on Drug Abuse established a researcher/provider partnership designed to test the effectiveness of research-based innovations in community-based treatment settings and facilitate the transfer of those innovations throughout the national treatment system. As a preliminary step in developing their local Clinical Trials Network, researchers and treatment providers within the Delaware Valley Node surveyed 317 staff members concerning their beliefs about addiction treatment. More than 80% of respondents supported increased use of research-based innovations, 12-step/traditional approaches, and spirituality in addiction treatment, while only 39% and 34%, respectively, endorsed the increased use of naltrexone and methadone maintenance. Also, 35% of respondents indicated that confrontation should be used more, and 46% agreed with discharging noncompliant patients. Individuals with more formal training tended to be less supportive of confrontation and more supportive of the increased use of medications. Implications for the clinical trials and technology transfer are discussed. Copyright 2001, Pergamon Press

Gallon SL, Gabriel RM, Knudsen JRW. The toughest job you’ll ever love: A Pacific Northwest Treatment Workforce Survey. Journal of Substance Abuse Treatment 24(3): 183–196, 2003. (15 refs.)

The training, recruitment, and retention of the most qualified professionals for the substance abuse treatment workforce is a crucial underlying strategy in the improvement of client care. Conducted in the year 2000, this survey of substance abuse treatment agency directors and clinical staff in the Pacific Northwest of the United States provides the first empirical estimates of issues surrounding these goals and points to the need for more aggressive strategies if a quality workforce is to be maintained and improved. Results of the survey indicate that there is an average of 25% turnover per year among treatment agency staff, and that the vast majority of this turnover is voluntary and stays within the treatment profession. Agency management and direct service staff differ in their perceptions of the recruitment and retention approaches currently in place in their agencies. Copyright 2003, Elsevier Science

Gotham HJ. Diffusion of mental health and substance abuse treatments: Development, dissemination, and implementation (review). Clinical Psychology: Science and Practice 11(2): 160–178, 2004. (117 refs.)

Theory and research regarding the diffusion of innovations and technology transfer have advanced our understanding of how new ideas and technologies are developed, disseminated, adopted, and implemented by individuals and organizations. Although diffusion has been studied in other fields, it is not often applied to mental health and substance abuse treatment. However, findings from diffusion-of-innovations research can assist in bridging research-practice gaps that lead to clients receiving treatments whose effectiveness has not been assessed or to clients not receiving the most effective treatments. This article reviews theory and research regarding the diffusion of innovations and highlights areas for application to mental health treatment, including the transportability of treatments into real-world settings, strategies to disseminate treatments, attributes of treatments that affect their adoption, and organizational change factors that affect implementation. Copyright 2004, Oxford University Press, Inc.

Grella CE, Hser YI, Teruya C, Evans E. How can research-based findings be used to improve practice? Perspectives from participants in a statewide outcomes monitoring study. Journal of Drug Issues 35(3): 469–483, 2005. (29 refs.)

This paper reports on the perspectives of substance abuse treatment providers and administrators who participated in a collaborative project to implement a statewide outcome monitoring system, the California Treatment Outcome Project (CalTOP). Program providers and county administrators were invited to discuss their perceptions regarding the relationship of research to treatment practice following completion of the project. Themes identified from this research-practice meeting were augmented by observations from program site visits and focus groups conducted with project participants during start-up. Participants articulated a range of actual and potential applications for using outcome data to improve treatment practice and to inform policy development, stressed several ways in which they could build upon the data-collection infrastructure developed for the project, and identified potential areas for continued program and staff development based on outcome findings. Future steps include identifying the organizational and workforce characteristics related to a program's readiness to incorporate research-based practices. Copyright 2005, Journal of Drug Issues, Inc.

Kerwin ME, Walker-Smith K, Kirby KC. Comparative analysis of state requirements for the training of substance abuse and mental health counselors. Journal of Substance Abuse Treatment 30(3): 173–181, 2006. (24 refs.)

Data on minimum state requirements for drug and alcohol counselors and mental health counselors in all 50 states and Washington, DC, suggest that training as a mental health counselor is primarily structured through formal education, whereas training as a substance abuse counselor resembles an apprentice model. Fewer states offer or require certification or licensure of substance abuse counselors, compared to mental health counselors. States that do offer such credentials for substance abuse counselors generally require more hours of supervised work experience and continuing education, but fewer hours of formal coursework and practicum courses, and a lower level of formal education. Although these different models for training are valid, they each have different implications for clinical practice, dissemination of research findings to practice, and management within the service delivery model. Copyright 2006, Elsevier Science Ltd.

Kirby KC, Benishek LA, Dugosh KL, Kerwin ME. Substance abuse treatment providers’ beliefs and objections regarding contingency management: Implications for dissemination. Drug and Alcohol Dependence 85(1): 19–27, 2006. (28 refs.)

Contingency management (CM) interventions are among the most effective methods for initiating drug abstinence, but they infrequently have been adopted by community drug and alcohol treatment programs. The primary purpose of this investigation was to determine the prevalence of specific beliefs that community treatment providers hold regarding contingency management interventions. We surveyed 383 treatment providers from three geographical areas of the United States regarding moral or ethical objections, negative side effects, practicality, limitations and positive opinions regarding tangible and social CM interventions. Results indicate that positive beliefs were surprisingly prevalent, with providers agreeing with an average of 67% of the positive statements regarding CM using tangible incentives and 54% indicating that they would be in favor of adding a tangible CM intervention to their treatment program. The most prevalent objections to incentive programs were that they cost too much, fail to address the underlying problems of addiction, and do not address multiple behaviors. Social incentives were viewed more favorably than tangible incentives and both were viewed more positively by providers who were supervisors, had advanced degrees, had more addictions experience, and had previous experience with tangible incentives. These findings have implications for improving the dissemination of this empirically-supported treatment. Copyright 2006, Elsevier Science

Knudsen HK, Ducharme LJ, Roman PM, Link T. Buprenorphine diffusion: The attitudes of substance abuse treatment counselors. Journal of Substance Abuse Treatment 29(2): 95–106, 2005. (71 refs.)

In October 2002, the Food and Drug Administration approved buprenorphine for use in the treatment of opioid dependence. Successful diffusion, adoption, and implementation of this medication within the treatment field depend in part on substance abuse counselors. Using questionnaire data obtained from 2,298 counselors in community-based treatment programs in the private and public sectors between June 2002 and July 2004, we explored the diffusion of this new treatment technique. Analyses indicate that a substantial proportion of the clinical workforce is unaware of the effectiveness of buprenorphine in the treatment of opiate addiction. Several variables predicted counselors' attitudes toward buprenorphine. Predictors included receipt of buprenorphine-specific training, educational attainment, years of experience, and 12-step orientation. Implications for the diffusion of this and other emerging treatment techniques are discussed. Copyright 2005, Elsevier Science Ltd.

Lemak CH, Alexander JA. Factors that influence staffing of outpatient substance abuse treatment programs. Psychiatric Services 56(8): 934–939, 2005. (32 refs.)

Objective: This study examined whether and how various organizational and environmental forces influence staffing in outpatient substance abuse treatment programs. Methods: The authors used data from the 1995 and 2000 waves of the National Drug Abuse Treatment System Survey (NDATSS), a telephone survey of unit directors and clinical supervisors. Multivariate analyses with generalized estimating equations were conducted. Two measures of staffing were modeled: the number of weekly treatment hours per client, and active caseload. Results: Managed care activity influenced active caseloads but not the number of treatment hours per client. Significant differences were noted in staffing levels among private for-profit, private nonprofit, and public treatment programs, with public units offering fewer hours per client and having larger caseloads. Units accredited by the Joint Commission on Accreditation of Healthcare Organizations offered more treatment hours per client. Conclusions: The results of this study contribute to the understanding of various influences on treatment staff time and caseloads. Understanding these relationships is critical for policy makers, managed care companies, and managers, because staffing levels have the potential to affect both the cost and the quality of treatment. Copyright 2005, American Psychiatric Association

McGovern MP, Fox TS, Xie H, Drake RE. A survey of clinical practices and readiness to adopt evidence-based practices: Dissemination research in an addiction treatment system. Journal of Substance Abuse Treatment 26(4): 305–312, 2004. (51 refs.)

Addiction research is challenged to disseminate evidence-based practices into routine clinical settings. The successful adoption of innovation must consider issues of fit, such as the characteristics, readiness, and attitudes of clinicians in the community. We constructed a survey to assess clinical practices and readiness to adopt certain evidence-based practices in addiction treatment programs. The instrument was administered to directors (n = 21) and clinicians (n = 89) from 24 public addiction treatment programs in New Hampshire (USA). Clinicians are more motivated to adopt some evidence-based practices (twelve-step facilitation, cognitive behavioral therapy, motivational interviewing, relapse prevention therapy) than others (contingency management, behavioral couples therapy, pharmacotherapies). Translational strategies for treatment development and research dissemination are discussed. Copyright 2004, Elsevier Science

McLellan AT, Carise D, Kleber HD. Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment 25(2): 117–121, 2003. (26 refs.)

As part of a larger study of the national substance abuse treatment system, the authors had an opportunity to interview the directors and the key staff from a nationally representative sample of 175 drug and alcohol treatment programs. Results indicated that within the previous 16 months, 15% of facilities had closed or stopped addiction treatment and an additional 29% had been reorganized under a different agency. There was a 53% turnover among directors and a similar rate among counselors within the previous year. Less than half the programs had a full-time physician or nurse, and very few programs had a social worker or psychologist. The predominant form of treatment was abstinence-oriented group counseling. The intake process typically required 2 to 4 hours to collect data required by managed care and city, state, and federal agencies. Very few programs had computers for clinical operations or decision support. These findings are disturbing and call into question the ability of the national treatment system to meet the complex demands of both the patients that enter this system and the agencies that refer to it. Copyright 2003, Elsevier Science

Meier PS, Donmall MC, McElduff P, Barrowclough C, Heller RF. The role of the early therapeutic alliance in predicting drug treatment dropout. Drug and Alcohol Dependence 83(1): 57–64, 2006. (54 refs.)

Background: To investigate the role of the therapeutic alliance in predicting length of retention in residential drug treatment. Methods: The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Counsellor and client information was assessed at intake, and the average total scores of client and counsellor ratings on the WAI-S (obtained during weeks 1-3) were use as the alliance measure. Length of retention and treatment completion (stay beyond 90 days) were used as measures of retention. Results: Clients with weak counsellor rated alliances dropped out of treatment significantly sooner than clients with strong counsellor rated therapeutic alliances, whether or not the model adjusted for individual counsellor effects and potential confounders including psychological wellbeing, treatment motivation and readiness, coping strategies, and attachment style. The client rated alliance did not predict length of retention. Apart from the alliance, pre-treatment crack use, secure attachment style and better coping strategies were associated with shorter retention, whereas greater confidence in treatment, older client age and better education predicted treatment completion. Counsellors with greater experience of delivering drug counselling retained clients longer. Conclusions: The findings of this study stress the importance of treatment professionals attending to the therapeutic alliance in drug treatment, as counsellors alliance ratings were found to be amongst the strongest predictors of dropout. Using alliance measures as clinical tools may help treatment practitioners to become aware of the risk of disengagement early on. Prospective studies are needed to evaluate whether strategies of reallocating clients with poor alliances to different counsellors lead to improvements in retention. Copyright 2006, Elsevier Science

Mulvey KP, Hubbard S, Hayashi S. A national study of the substance abuse treatment workforce. Journal of Substance Abuse Treatment 24(1): 51–57, 2003. (15 refs.)

This study's purpose is to gain a current perspective on the substance abuse treatment field's workforce. The data are from the Retrospective Study of treatment professionals designed to document how the Treatment Improvement Protocols published by the Center for Substance Abuse Treatment have influenced the implementation of best practices. The Retrospective Study consisted of a two-wave cross-sectional survey with telephone follow-up. Data for this study were from demographic information on Wave 1 study participants, which had a response rate of 80.1% (N = 3,267). The results of the study showed that most treatment professionals are White (84.5%) and middle-aged (i.e., between 40 and 55 years old) and slightly more are female (50.5.0%) than male (49.5%). Treatment professionals tend to enter the field and stay in it, and almost 80.0% of respondents possess a bachelor's degree or higher. In addition, most treatment professionals are licensed or certified and treat clients from different racial and ethnic backgrounds than themselves. Implications for the provision of treatment services are discussed. Copyright 2003, Elsevier Science Ltd

NAADAC Education and Research Foundation. Salary and Compensation Study of Alcoholism and Drug Abuse Professionals, 1995. Arlington, VA: NAADAC, 1995.

The study of alcoholism and drug abuse counselor salaries and incomes was commissioned by NAADAC's Education and Research Foundation to provide a national profile of the profession's compensation. The results also provide insight into several career pathways common to the profession and help to confirm or dispel many notions regarding compensation in a variety of occupations held by those trained as counselors. Information was gathered from 746 NAADAC members who completed a 4 page mailed questionnaire. This information is presented in 40 tables and covers some of the following areas: normal weekly hours and length of service in primary employment; earnings from primary employment for government employees compared with other professionals; respondents' years of experience and formal education; completed formal education and subject of highest degree earned by salaried respondents; and characteristics of employing organization. Copyright 1993, Project Cork

Olmstead TA, Johnson JA, Roman PM, Sindelar JL. What are the correlates of substance abuse treatment counselor salaries? Journal of Substance Abuse Treatment 29(3): 181–189, 2005. (20 refs.)

This article identifies and measures the key correlates of substance abuse treatment (SAT) counselor salaries. The data come from the 2002–2003 wave of the National Treatment Center Study that consists of approximately 1,500 full-time counselors from nationally representative samples of public and private SAT facilities. We used interval regression models to estimate the relationship between annual salary and numerous counselor and organizational characteristics. We found that counselor characteristics associated with annual salary include education, tenure in the SAT field, licensure, race, recovery status, and administrative responsibilities above and beyond duties as a full-time counselor. Organizational characteristics associated with counselor salary include accreditation status, hospital ownership, and the population density of the county where the facility is located. Taken together, these factors explain approximately 50% of the total variation in SAT counselor salaries. Copyright 2005, Elsevier Science Inc.

Stoffelmayr BE, Mavis BE, Kasim RM. Substance abuse treatment staff: Recovery status and approaches to treatment. Journal of Drug Education 28(2): 135–145, 1998. (14 refs.)

Recovery status is an important characteristic of staff members working within substance abuse treatment. Recovering and nonrecovering staff members were contrasted previously, however there is a third group: Individuals who are not recovering themselves but are part of families with recovering or addicted members. The purpose of the present study is to compare background, roles within program and approaches to treatment of these three groups. Six hundred and thirty-four staff members of fifty-one treatment programs completed questionnaires. Five hundred and seventy-five completed an item indicating their recovery status. Forty-four percent identified themselves as nonrecovering, 30 percent as recovering, and 26 percent as nonrecovering but part of families with an addicted or recovering member. Nonrecovering staff with addicted or recovering family members differed from the other two groups on gender, more of them were female, but were similar to nonrecovering staff in their approach to treatment but fell between recovering and nonrecovering staff on measures of roles within programs and background. Recovering counselors reported to pursue a wider range of treatment goals and to use more varied treatment techniques than nonrecovering counselors. The implication of these findings for training and licensure of paraprofessionals in the field of substance abuse treatment is discussed.

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