Patricia Ebener

Prevalence and Characteristics of Clients with Co-Occurring Disorders in Outpatient Substance Abuse Treatment

This article reports on the prevalence of probable mental health disorders among clients entering outpatient substance abuse treatment, their clinical characteristics, and past access to substance abuse and mental health care. Four hundred fifteen individuals (74% of those eligible) entering three publicly funded outpatient substance abuse treatment facilities in Los Angeles County were screened for a probable mental health disorder. Of the 210 with a positive screener (just over 50% of those screened), 195 (93%) were interviewed. Depression and anxiety were the most common disorders, and more than a third had two or more probable disorders. Close to 70% reported using alcohol, and almost half reported using crack or cocaine. Half had never received any mental health treatment, and for a third this was their first episode of addiction treatment; 22% were on psychotropic medications. Levels of physical and mental health functioning were lower than the 25th percentile of the U.S. population norms. Our results indicate high rates of co‐occurring mental health disorders among individuals entering these outpatient substance abuse treatment clinics in Los Angeles. Identifying people with probable mental health disorders as they enter treatment has the potential to increase access to care among those with limited prior access.

The Getting To Outcomes Demonstration and Evaluation: An Illustration of the Prevention Support System

Communities are increasingly being required by state and federal funders to achieve outcomes and be accountable, yet are often not provided the guidance or the tools needed to successfully meet this challenge. To improve the likelihood of achieving positive outcomes, the Getting To Outcomes (GTO) intervention (manual, training, technical assistance) is designed to provide the necessary guidance and tools, tailored to community needs, in order to build individual capacity and program performance. GTO is an example of a Prevention Support System intervention, which as conceptualized by the Interactive Systems Framework, plays a key role in bridging the gap between prevention science (Prevention Synthesis and Translation System) and prevention practice (Prevention Delivery System). We evaluated the impact of GTO on individual capacity and program performance using survey- and interview-based methods. We tracked the implementation of GTO and gathered user feedback about its utility and acceptability. The evaluation of GTO suggests that it can build individual capacity and program performance and as such demonstrates that the Prevention Support System can successfully fulfill its intended role. Lessons learned from the implementation of GTO relevant to illuminating the framework are discussed.

Trauma exposure and retention in adolescent substance abuse treatment

Trauma exposure and related symptoms interfere with adult adherence to drug treatment. Whether these findings hold true for adolescents is unknown. We examined trauma exposure, PTSD symptoms, and psychosocial functioning among 212 adolescents upon admission to long-term residential drug treatment and examined retention in treatment at 6 months. Seventy-one percent reported lifetime trauma exposure, and 29% of the trauma-exposed met criteria for current PTSD. Trauma-exposed adolescents reported more behavioral problems, with gender differences apparent. We divided the sample into three groups: no trauma exposure (21%), trauma-exposed without PTSD (59%), and trauma-exposed with PTSD (20%). Survival analysis showed that trauma-exposed adolescents without PTSD left treatment sooner than the nonexposed. Need for attention to trauma in substance abuse treatment programs is discussed.

Technical Assistance as a Prevention Capacity-Building Tool: A Demonstration Using the Getting To Outcomes® Framework

Demands on community-based prevention programs for performance accountability and positive outcomes are ever increasing in the face of constrained resources. Relatively little is known about how technical assistance (TA) should be structured to benefit community-based organizations and to lead to better outcomes. In this study, data from multiple sources were used to describe an effective TA model designed to improve the capacity of community-based organizations to plan, implement, and evaluate prevention programming. This article is the first of its kind to provide detailed analyses of the TA delivered to community-based organizations to build substance abuse prevention capacity. The results of this study describe the range of TA services provided and the importance of two-way communication between the TA provider and recipient. TA recipients reported high satisfaction and an improved understanding of targeted TA activities. However, achieving these benefits requires significant program staff time, and not all skills were successfully transferred. Results from this study suggest how TA may be structured to be effective in supporting quality prevention programming in community settings.

How important are client characteristics to understanding treatment process in the therapeutic community

Prior research has demonstrated that therapeutic communities (TCs) are effective at improving posttreatment outcomes for substance abusers. However, little is known about the in‐treatment experience for clients with different backgrounds, experiences, and needs. The aim of this study is to examine the in‐treatment experience for different clients by exploring the relationships between treatment process and client characteristics. A comprehensive measure of treatment process, operationalized as Community Environment and Personal Change and Development and change was administered to 447 adults and 148 adolescents receiving treatment at community‐based TC programs in New York, California, and Texas. Data on demographic characteristics, substance use and treatment history, and client risk factors were extracted from intake interviews and analyzed separately for adolescent and adult residents. Multivariate general linear models were used to examine the effect of client variables on treatment process, after controlling for treatment duration and program effects. Within adult programs, clients who were 25 years or older, female, and had a prior drug treatment experience had higher Community Environment scores. Adolescents with one or more arrests within the past 2 years had lower scores on both process dimensions of Community Environment and Personal Development and Change. Our results indicate the need to understand why adult clients who are younger, male, and have no prior treatment history and adolescent clients with recent arrests reported lower ratings of treatment process. Future research should also examine the role of modifiable mediators so that appropriate strategies to enhance therapeutic engagement may be developed as necessary.

Drug-Abusing Homeless Clients in California's Substance Abuse Treatment System

As many as one-half to three-fourths of homeless persons have diagnoses of alcohol or other drug dependence. Rates of alcohol and other drug use disorders, and the social costs associated with untreated substance disorder, are higher among homeless than nonhomeless persons. Despite the high level of need for treatment, relatively few substance-abusing homeless individuals receive treatment for their drug problems, suggesting difficulties in accessing treatment. This study addresses access by focusing on the select group of homeless drug users who have overcome barriers to enter the substance abuse treatment system in California and by examining differences between these homeless treatment clients and nonhomeless drug-using clients. Major findings from bivariate and logistic regression analyses performed on 187 homeless and 1,820 nonhomeless treatment clients are that homeless clients were more likely than nonhomeless clients to have a primary drug problem of cocaine/crack and to be injecting methamphetamine and other amphetamines, and that they were no less likely to complete their treatment program. An implication of this study is that homeless persons with primary drug problems appear to have no less commitment to achieving treatment goals than their nonhomeless counterparts.

Intervening with practitioners to improve the quality of prevention: One year findings from a randomized trial of Assets-Getting To Outcomes

There continues to be a gap in prevention outcomes achieved in research trials versus those achieved in “real-world” practice. This article reports interim findings from a randomized controlled trial evaluating Assets-Getting To Outcomes (AGTO), a two-year intervention designed to build prevention practitioners’ capacity to implement positive youth development–oriented practices in 12 community coalitions in Maine. A survey of coalition members was used to assess change on individual practitioners’ prevention capacity between baseline and one year later. Structured interviews with 32 program directors (16 in the intervention group and 16 in the control group) were used to assess changes in programs’ prevention practices during the same time period. Change in prevention capacity over time did not differ significantly between the intervention and control groups. However, in secondary analyses of only those assigned to the AGTO intervention, users showed greater improvement in their self-efficacy to conduct Assets–based programming and increases in the frequency with which they engaged in AGTO behaviors, whereas among non-users, self-efficacy to conduct Assets–based programming declined. Interview ratings showed improvement in several key areas of performance among intervention programs. Improvement was associated with the number of technical assistance hours received. These results suggest that, after one year, AGTO is beginning to improve the capacity of community practitioners who make use of it.

Getting To Outcomes: a community-based participatory approach to preventive interventions.

Similar to how research can be improved when community members are involved (i.e., Community-based participatory research, or CBPR), this brief report argues how preventive interventions can also be so improved (i.e., Community Based Participatory Interventions or CBPI). The paper describes how to facilitate CBPI, RAND and University of South Carolina researchers developed a prevention process and corresponding technical assistance package, called Getting To Outcomes (GTO).

An intervention to improve program implementation: findings from a two-year cluster randomized trial of Assets-Getting To Outcomes

BackgroundStudies have shown that communities have not always been able to implement evidence-based prevention programs with quality and achieve outcomes demonstrated by prevention science. Implementation support interventions are needed to bridge this gap between science and practice. The purpose of this article is to present two-year outcomes from an evaluation of the Assets Getting To Outcomes (AGTO) intervention in 12 Maine communities engaged in promoting Developmental Assets, a positive youth development approach to prevention. AGTO is an implementation support intervention that consists of: a manual of text and tools; face-to-face training, and onsite technical assistance, focused on activities shown to be associated with obtaining positive results across any prevention program.MethodsThis study uses a nested and cross-sectional, cluster randomized controlled design. Participants were coalition members and program staff from 12 communities in Maine. Each coalition nominated up to five prevention programs to participate. At random, six coalitions and their respective 30 programs received the two-year AGTO intervention and the other six maintained routine operations. The study assessed prevention practitioner capacity (efficacy and behaviors), practitioner exposure to and use of AGTO, practitioner perceptions of AGTO, and prevention program performance. Capacity of coalition members and performance of their programs were compared between the two groups across the baseline, one-, and two-year time points.ResultsWe found no significant differences between AGTO and control group’s prevention capacity. However, within the AGTO group, significant differences were found between those with greater exposure to and use of AGTO. Programs that received the highest number of technical assistance hours showed the most program improvement.ConclusionsThis study is the first of its kind to show that use of an implementation support intervention-AGTO -yielded improvements in practitioner capacity and consequently in program performance on a large sample of practitioners and programs using a randomized controlled design.ClinicalTrials.gov identifierNCT00780338

Measuring Changes in Client-Level Treatment Process in the Therapeutic Community (TC) with the Dimensions of Change Instrument (DCI)

The Dimensions of Change Instrument (DCI) measures treatment process in residential therapeutic community (TC) settings. It summarizes eight factors of treatment process from a client perspective. We present evidence of the reliability of the DCI for assessing both adult (N = 519) and adolescent (N = 474) client perceptions of treatment process. The DCI factors significantly increase over time, with increases consistently seen across all DCI factors for adults. We highlight areas for future DCI modifications to broaden its applicability to adolescents. Our findings show that clinicians can use the DCI to evaluate adult client progress and target areas for improving quality of care.