IADDA Conference Oakbrook, IL October 3 rd , 2007

1. Implementing Evidence-Based Practices: Strategies in Mental Health and Substance Abuse Child and Adolescent Programs IADDA Conference Oakbrook, IL October 3rd, 2007

2. Panel Participants: Presenters: • Susan Harrington Godley, Rh.D.—Chestnut Health Systems • Danielle Kirby, MPH, MSEd—Division of Alcoholism and Substance Abuse (DASA) • Andrea Kuebbeler, LCSW—Alternatives, Inc. • Amy Starin, LCSW—DMH Child & Adolescent NetworkHelen R. Stewart, LCSW—Pillars Discussant: • Stanley G. McCracken, Ph.D., LCSW, RDDP— The University of Chicago, School of Social Service Administration

3. Overview of Evidence-Based Practices

4. Ways of Viewing EBP • EBP is a process. EBP is a way of doing practice that integrates the best evidence with clinical expertise and consumer values. (EBP as a verb.) (Sackett et al., 2000) Practitioner Expertise Best Evidence EBP Client Values & Preferences

5. Ways of Viewing EBP • EBP is a product. An evidence-based practice is any practice that has been established as effective through scientific research according to some set of explicit criteria. (EBP as a noun.) (Drake, 2001) • EB Interventions. (A-CRA, MET/CBT5) • EB Skill sets. (CBT, Behavioral Parent Training)

6. Definition of Implementation “…Specified set of activities designed to put into practice an activity or program of known dimensions…such that independent observers can detect its presence and strength.” (Fixsen et al, 2004, p. 5)

7. Fixsen et al., 2004, p. 29

8. Definition of Fidelity • Strategies used to monitor the faithful delivery of a manual-guided behavioral intervention • Important dimensions include • adherence (i.e., extent to which intervention procedures were delivered as prescribed in the treatment manual) • competence (i.e., qualitative measure of the skillfulness in which intervention procedures are delivered)

9. Different Types of Manuals • Session Driven • Procedure Driven • Principle Driven

10. Study of Therapists’ Reactions to Manual-Guided Therapy • Qualitative Interview • Questions • Compare & contrast doing therapy with & without a manual. • Were there times when you deviated & why? • How was manual-based therapy able to address individual needs?

11. Therapists Interviewed • At least 3 from each intervention; total of 16 therapists and 3 CM • 1 to 18 months experience with manual • Age ranges from 24-55 with a M age of 37 • M of 7 years in drug abuse counseling, services to adolescent, and services to family • 10 had master’s degrees, 6 had bachelor degrees, and 3 had doctoral degrees • 5 had previous experience with M-G therapy

12. Results

13. Structure, Consistency, Focus • All 19 therapists said that MGT provided structure & consistency • 30% noted it helped them prepare for a session • 6 noted it helped them focus during a session • 4 out of 6 supervisors talked about quality control

14. Restrictiveness • 57% noted some aspect of restrictiveness • 42% said it limited their ability to respond to individual needs • Cut across all interventions, but highest percent (70%) were in relation to group

15. Exceptions • 4 therapists discussed how they were able to incorporate their personal style and individualize the treatment. • the use of the check-in time at the beginning • choosing role-play situations related to circumstances of the group • 74% indicated the manual they used was flexible enough to address individual needs

16. Division of Mental HealthChild & Adolescent Services:Approach to EBP Amy Starin Division of Mental Health Child & Adolescent Network

17. Division of MH – C & A Services Approach to EBP • Advisory Committee • Started in November 2005 • Membership includes • CMH Agencies • University Professors • Parents • Advocacy Organizations

18. DMH C & A Provider Survey • 303 responses • 75% knew what EBP was • Agencies not prepared to assist clinicians in accessing or applying research • 44% report having been ‘trained’ in EBP Mostly through a workshop – ineffective • 92% Interested or Very interested in learning in EBP

19. EBP – The Noun or the Verb? • An extremely diverse client base • Very narrowly defined EBP interventions • DMH decision………..

20. The “VERB”Evidence Informed Practice Process of Infusing concepts of science into our C & A system • Individual Assessment • Define a client specific question • What does the research say? • Review evidence with client and make a decision based on client values • Implement the intervention • Measure the outcomes & evaluate

21. Evidence Informed Practice Definition “A collaborative effort by children, families, and practitioners to identify and implement practices that are appropriate to the needs of the child and family, reflective of available research, and measured to ensure the selected practices lead to improved meaningful outcomes.”

22. 5 Pronged Approach 1. Evidence Based Skill Sets 2. Agency Leadership Seminars 3. University Partnerships 4. Consumer Education 5. Policy Implications

23. EBP Skill Sets - Pilot • CBT & Behavioral Parent Training • 22 Pilot agencies (FY 07/08) • 8 Didactic days & twice monthly phone supervision over the course of 12 months • University Evaluation

24. Provider Agency Leadership Training • Quarterly seminars at 3 locations in the state.

25. University Partnerships • 3 State University programs have developed C & A EBP Certification programs for 2nd year masters students. Students are being admitted this year. • Importance of collaboration between Academic and Field training.

26. Consumer Education • Consumers are powerful change agents • Consumer conferences and speaking to advocacy groups

27. State Policy Barriers & Supports • Development of Action Steps for each level of the system. • Division of Mental Health • University • Agency • Clinician • Consumer Advocacy Group • Consumer Family

28. Division of Mental HealthChild & Adolescent Services:A Provider’s Perspective Helen R. Stewart, LCSW Pillars

29. Parent Behavior Training:Implementing in community-based settings • Different Perspectives and integration of them into one treatment- common language/common ground: • Initial skepticism about EBP • Psychodynamic treatment vs. PBT • Interpersonal therapy vs. PBT

30. Parent Behavior Training, cont’d • Engaging parents: • “Pre-treatment” Phase • Time Frames • Constantly revisiting engagement

31. Parent Behavior Training, cont’d • Adapting PBT: • Trainers adaptations • Clinicians adaptations: • Home-based services • Complex, multi-problem families • Multiple caretakers, multiple siblings • Crisis • Family level of functioning

32. Parent Behavior Training, cont’d • Cultural adaptations: • Language • Cultural perspectives on parenting in general • Handouts

33. Division of Alcoholism and Substance Abuse Adolescent Coordination Grant Danielle Kirby Division of Alcoholism and Substance Abuse Chicago, IL

34. DASA Why Evidence-Based Practices? • Outcomes • NOMs (National Outcome Measures) / State Plan • Performance-Based Contracting • Illinois State Adolescent Coordination Grant (IL-SAC)

35. IL-SAC Illinois Adolescent Substance Abuse Treatment Coordination Initiative • Funded by SAMHSA/CSAT (Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment) • 3 years: August 1, 2005 – July 31, 2008 • Year 3: August 1, 2007 – July 31, 2008 • More Information: www.IllinoisTreatmentWorks.org

36. IL-SAC 13 Required ActivitiesActivity #4 4.Evidence-based treatment: Identify barriers (fiscal, regulatory, and policy) that impede the adoption and provision of accessible evidence-based treatment across the full continuum of care recommended by the American Society of Addiction Medicine (ASAM). Devise and implement strategies, in concert with all other State-agencies that may fund and/or regulate these services, to improve the access to treatment, increase capacity and quality, and expand the available continuum in communities and throughout the State implementing treatment interventions with a scientific evidence base for the population to be served.

37. Considerations in ImplementingEvidence-Based Practices • Defining • SAMHSA’s National Registry of Evidence Based Programs & Practices (NREPP) • 7 Options • No MISA EBP • Manual-Based Treatment • Noun vs. Verb • Practice-Based Evidence • Funding: Training and Technology Transfer • IL-SAC “Pilot” Program • DMH’s Approach

38. Division of Alcoholism and Substance Abuse Adolescent Coordination Grant:EBT Implementation Susan H. Godley Chestnut Health Systems Bloomington, IL

39. Overview • DASA released application for participation in GAIN and EBT training in Jan ’06 • 8 out of 22 applicant agencies were chosen to participate and began the training process in April ‘06

40. 4-day centralized training session Upload session recordings & data to the web; Get expert ratings and narrative feedback Performance Indicators are monitored Record clinical and supervision sessions Treatment Manual and Knowledge Test EBT Technical Assistance After certification monthly fidelity checks Certification Requirements are clearly delineated & monitored Coaching calls As needed

41. A-CRA Clinician CertificationRequirements • Take a knowledge test • Attend the 3.5 day training • Attend coaching calls • Participate in local supervision sessions • Demonstrate competency on 9 core A-CRA procedures through DSR reviews

42. Sample Procedure Rating 1 2 3 4 5 | | | | | poor needs satisfactory very excellent improvement good Caregiver Overview, Rapport Building, and Motivation: 48. ____ ____ Provided an overview of ACRA 49. ____ ____ Set positive expectations 50. ____ ____ Reviewed research regarding parenting practices 51. ____ ____ Identified CG reinforcers for continued work 52. ____ ____ Kept discussion (about adolescent) positive

43. Each column represents a different session A 3 or better on all components denotes competency

44. Narrative Comments Are Also Provided

45. Progress: MET/CBT5 • 3 sites sent 10 staff to trainings • Appears to be implemented well at 2 agencies • Third agency still working towards implementation

46. Progress: A-CRA • Five Sites sent 26 Individuals to trainings • One agency chose not to implement • Being Implemented at 4 agencies

47. Barriers Lack of understanding/ commitment to time demands of certification process Limited clinical supervision time Advantages Like having an approach that all are trained on instead of everyone ‘doing their own thing’ Most felt these approaches worked well with their clients Barriers/Advantages to EBT Implementation

48. Division of Alcoholism and Substance Abuse Adolescent Coordination Grant:A Provider’s Perspective Andrea Kuebbeler Alternatives, Inc. Chicago, IL

49. IL DASA EBT ProjectAlternatives, Inc. • Why we chose to participate. • Outcomes for Adolescent substance abusers • Skill building for Staff • Ability to generate increased funding • Participation in a learning community • Advance adolescent substance abuse treatment within Illinois

50. Barriers Encountered • Equipment costs • Supervision/Management Time • Staff Turnover • Staff Resistance • Data Collection • Sustainability