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Lehman W.E.K., Simpson D.D., Knight D. K. et al.
Psychology of Addictive Behaviors: 2011, 25(2), p. 252–261.
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This review encapsulates the range of treatment assessment and improvement tools developed over decades by the Texas Christian University, widely recognised as the most comprehensive and systematic attempt to map the processes involved in treatment and to link these to interventions to improve outcomes for the client.
Summary Sustained and effective use of evidence-based practices in substance abuse treatment services faces both clinical and contextual challenges. In this overview, implementation approaches are reviewed that rely on variations of plan-do-study-act (PDSA) cycles, but most emphasise conceptual identification of core components for system change strategies. A two-phase procedural approach is therefore presented based on the integration of Texas Christian University (TCU) models and related resources for improving treatment process and programme change.
Phase 1 focuses on the dynamics of clinical services, including stages of client recovery (cross-linked with targeted assessments and interventions), as the foundations for identifying and planning appropriate innovations to improve efficiency and effectiveness. Research under this heading has shown that clients presenting to treatment with higher motivation are more likely to participate in treatment during the early months. Better participation during early treatment is then associated with greater rapport with counsellors. Clients who report stronger therapeutic relationships with counsellors show greater improvements in psychological functioning during treatment in the areas of self-esteem, depression, anxiety, social integration, and decision-making. Improved psychological functioning is then associated with favourable behaviour changes (eg, self-report and urinalysis measures of drug use). The model also portrays how specialised interventions as well as health and social support services promote stages of recovery-oriented change. Cognitive strategies (especially those for increasing levels of treatment readiness among low-motivated clients) have proven useful for improving subsequent therapeutic relationships and retention. Assessment instruments that gauge client and programme performance provide a foundation for systematic treatment monitoring and management strategies, and for tracking the evidence for using targeted interventions to improve treatment quality.
Phase 2 shifts to the operational and organisational dynamics involved in implementing and sustaining innovations (including the stages of training, adoption, implementation, and practice). Once relevant new clinical practices are identified, the process of implementing them properly begins with consideration of programme needs and resources, structural and functional characteristics, and general readiness to embrace innovations. Preparation for change is a critical feature for successful implementation. This includes review of both facilities management/services and the clinical model for service delivery. A review of facilities management and services flow helps identify where innovative practices fit into the larger organisational structure to help assure that they are compatible with other organisational practices. A thorough review of the clinical model for care planning helps identify areas where improvements in clinical practices are needed. Surveys of staff needs and functioning provide diagnostic information regarding staff readiness and ability to accept the planned changes. Basically, programmes need to 'know themselves' well in order to successfully guide their organisation toward survival and improvement.
The featured review describes this comprehensive system of TCU assessments and interventions for client and programme-level needs and functioning, and offers examples and guidelines for applications in practical settings.
commentary The featured review encapsulates the impressive range of treatment assessment and improvement tools developed over decades by the Texas Christian University's Institute of Behavioral Research, all made freely available from their web site. This suite is widely recognised as the most comprehensive and systematic attempt to map the processes involved in treatment and to link these to interventions to improve outcomes for the client.
The therapeutic and assessment (of patients, staff and organisational health) tools described in this review have been implemented in Britain, notably by the US centre responsible for the featured review. They worked with 44 voluntary and statutory substance use treatment services in and around Manchester, Birmingham, and Wolverhampton. Each took a 'snapshot' of their clients using the US centre's CEST (Client Evaluation of Self and Treatment) forms for the clients, which asked them to rate themselves on statements representing their motivation and readiness for treatment, psychological and social functioning, and engagement with treatment. At the same time, counsellors at the services completed ORC (Organizational Readiness for Change) forms assessing their perceptions of the service they worked for and of their own professional functioning and needs. This work, which represents the most wide-ranging investigation of the organisational health of British treatment services to date, found clients engaged best when services fostered communication, participation and trust among staff, had a clear mission, but were open to new ideas and practices.
Studies are lacking on whether it is possible to deliberately engineer organisational change along the dimensions measured by these assessments in ways which actually improve treatment engagement or outcomes. Such studies are rare probably because change along dimensions like mutual trust among staff, or willingness to listen to their suggestions, cannot simply be introduced by researchers and then studied. However, at least one study has shown that feedback of scores from the ORC organisational health scale developed by the TCU can motivate less well functioning agencies to engage in an improvement programme. Agencies which scored as less open Lower scores on cohesion, communication, and openness to change were associated with a higher likelihood of further work in making improvements in the area(s) identified in an assessment and training workshop designed to improve organisational functioning. to change and staff suggestions – the ones which would normally be least likely to engage in a change process – were the ones most likely to commit to change The study was unable to report whether they actually followed through on this commitment. when faced with the evidence of their shortcomings.
This draft entry is currently subject to consultation and correction by the study authors.
Last revised 15 November 2011
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REVIEW 2005 The motivational hallo