Jack M. Greener

Assessing organizational readiness for change

A comprehensive assessment of organizational functioning and readiness for change (ORC) was developed based on a conceptual model and previous findings on transferring research to practice. It focuses on motivation and personality attributes of program leaders and staff, institutional resources, and organizational climate as an important first step in understanding organizational factors related to implementing new technologies into a program. This article describes the rationale and structure of the ORC and shows it has acceptable psychometric properties. Results of surveys of over 500 treatment personnel from more than 100 treatment units support its construct validity on the basis of agreement between management and staff on several ORC dimensions, relationships between staff organizational climate dimensions and patient engagement in treatment, and associations of agency resources and climate with organizational stability. Overall, these results indicate the ORC can contribute to the study of organizational change and technology transfer by identifying functional barriers involved.

Drug Abuse Treatment Process Components that Improve Retention

BACKGROUND Longer retention has been the most consistent predictor of favorable drug abuse treatment outcomes, but key therapeutic and patient engagement indicators of treatment process need to be more clearly established. METHODS An integrative model representing treatment dynamics was tested for explaining long-term program retention. It was based on a multisite sample of 527 daily opioid users who remained in methadone maintenance a minimum of 3 months. All had been assigned randomly to a counseling condition at admission (i.e., cognitively enhanced or standard), and information obtained from patient files, as well as periodic assessments completed by patients and their counselors in the first 90 days after admission were the sources of predictors. RESULTS Counseling enhancements (using node-link mapping, a visual representation tool for improving communication and problem solving) contributed to stronger therapeutic relationships between counselor and patient, which in turn had a positive reciprocal relationship with patient engagement (session attendance). Pretreatment motivation measured at intake was also related to higher engagement. More positive therapeutic relationships (in months 1 and 2) led to lower levels of during-treatment drug use (defined from urinalysis results in months 2 and 3), and better session attendance and therapeutic relationships both predicted longer retention. In addition, lower drug use during treatment was related to longer retention. CONCLUSIONS Major conceptual domains of drug abuse treatment process were identified in community-based programs and their interrelationships with retention specified. As intermediate (during treatment) criteria, they can help guide functional improvements in program effectiveness as illustrated with our counseling enhancements.

Client engagement and change during drug abuse treatment

Previous work has shown length of time in drug abuse treatment is associated with better outcomes, but the role of therapeutic engagement and process needs further examination. In this study, the total number of counseling sessions attended by 557 clients in their first 90 days of community-based outpatient treatment was examined in relation to indicators of treatment delivery and progress. Significant client improvements were found on behavioral criteria and psychosocial functioning during the first 3 months of treatment, and session attendance was positively related to favorable behavioral changes as well as to positive perceptions by clients and counselors of their therapeutic interactions. Client background, treatment motivation, and therapeutic focus of counseling in Month 1 were significant predictors of session attendance in the first 3 months following admission to methadone treatment.

Integrative modeling of client engagement and outcomes during the first 6 months of methadone treatment.

Integrative models containing client and treatment components were tested in a sample of 396 daily opioid users from three methadone maintenance treatment sites. Measures included client motivation at intake as well as repeated assessments of therapeutic engagement (relationships between clients and their counselors, session attendance, and results of urine testing) during the first 6 months of treatment. There was a positive effect of pretreatment motivation on greater engagement and a reciprocal positive relationship between components of engagement and their effects on lowering drug use throughout treatment. Further analyses addressed differential effects of group versus individual counseling and showed that group session attendance was associated with higher rates of drug-negative urines.

Modeling Year 1 Outcomes with Treatment Process and Post-treatment Social Influences

Follow-up studies of drug user treatment generally find significant improvements in client functioning, but information about the therapeutic components associated with client behavioral changes over time is limited. An integrative model developed previously to predict treatment retention was expanded and applied to post- treatment outcomes. This study is based on 321 daily opioid users treated in three methadone treatment clinics. Effects of pretreatment motivation, treatment process measures representing therapeutic relationship, counseling session attendance, and length of treatment are examined in relation to measures of family relations, peer deviancy, return to treatment, drug use, and criminality in the year after treatment. Models were tested in two stages. The first was built on a during-trealment process model for predicting time in treatment to include post-treatment outcomes. The second model was expanded further to include the effects of intervening social support variables as predictors of post-treatment drug and criminality outcomes. The results supported both models and emphasize the importance of considering social influences and related community contextual factors that affect recovery dynamics.

Organizational Readiness for Change in Correctional and Community Substance Abuse Programs

Significant needs exist for increased and better substance abuse treatment services in our nations prisons. The TCU Organizational Readiness for Change (ORC) survey has been widely used in community-based treatment programs and evidence is accumulating for relationships between readiness for change and implementation of new clinical practices. Results of organizational surveys of correctional counselors from 12 programs in two states are compared with samples of community-based counselors. Correctional counselors perceived strong needs for new evidence-based practices but, compared to community counselors, reported fewer resources and less favorable organizational climates. These results have important implications for successfully implementing new practices.

Development and Validation of a Client Problem Profile and Index for Drug Treatment

The development of the Client Problem Profile and Index are described, and initial concurrent and predictive validity data are presented for a sample of 547 patients in outpatient methadone treatment. Derived from the TCU Brief Intake for drug treatment admissions, the profile covers 14 problem areas related to drug use (particularly cocaine, heroin/opiate, marijuana, other illegal drugs, and multiple drug use), HIV risks, psychosocial functioning, health, employment, and criminality. Analyses of predictive validity show the profile and its index (number of problem areas) were significantly related to therapeutic engagement, during-treatment performance, and posttreatment follow-up outcomes. Low moderate to high moderate effect sizes were observed in analyses of the indexs discrimination.

During-Treatment Outcomes among Female Methamphetamine-Using Offenders in Prison-Based Treatments.

An increasingly important treatment group is the expanding population of methamphetamine-using female offenders. This study focused on women methamphetamine-using offenders (n = 359) who were treated either in a modified therapeutic community (TC) program (“Clean Lifestyle is Freedom Forever” [CLIFF]-TC: n = 234) designed for non-violent offenders with significant impairment from methamphetamine use, or the standard outpatient (OTP) treatment (OTP: n = 125). All participants were assessed on motivation, psychological and social functioning, and treatment engagement before and during treatment. A multilevel repeated measures analysis examined changes between intake and end of Phase 2 treatment. Both CLIFF-TC and the traditional OTP treatments were shown to improve psychosocial functioning, with significant changes on measures of self esteem, depression, anxiety, decision making, hostility, risk taking, and criminal thinking errors. Effect size comparisons indicated treatment gains were larger in the CLIFF-TC than in the OTP group. Both groups rated treatment engagement measures of participation, satisfaction, and counselor rapport to be very high. These results have positive implications for managing and improving treatment of methamphetamine-using women offenders because psychological improvements during treatment have been linked to better post release outcomes.

Evaluation of WaySafe: A Disease-Risk Reduction Curriculum for Substance-Abusing Offenders

With a focus on reducing disease risk behavior in the community, a six-session curriculum, WaySafe, was developed to increase positive decision-making skills among soon-to-be-released inmates participating in a therapeutic community substance abuse treatment program. The intervention used TCU Mapping-Enhanced Counseling as an approach to focus on cognitive aspects of risky sexual and drug use behaviors in an effort to improve problem recognition, commitment to change, and strategies for avoiding behavioral risks of infections. A total of 1393 inmates from eight different institutions in two states were randomly assigned to receive WaySafe or treatment as usual (TAU). Baseline and follow-up surveys measured knowledge, confidence, and motivation regarding general HIV information, risky sex and drug use, HIV testing, and risk reduction skills. WaySafe participants had significantly better scores on all measures at follow-up than did TAU participants, supporting the efficacy of WaySafe in improving knowledge, motivation, and confidence in avoiding risky behaviors.