A review of the book, Motivating
Substance Abusers to Enter Treatment: Working with Family Members, by Jane
Ellen Smith & Robert J. Meyers. By “The
Journal Critical Psychology, Counselling, and Psychotherapy” Vol. 8, No.1,
March 2008.
This program must be recommended for its emphasis on empowering family
members, used to experiencing high levels of helplessness, as well as the
strong evidence for the effectiveness of this program in motivating substance
abusers to engage in treatment. Overall
this book is effective in providing a clear and detailed guide to initiating
and delivering this program for practitioners in a range of clinical settings.
There
is a great article on addiction treatment at MSN here is the link http://health.msn.com/health-topics/addiction/articlepage.aspx?cp-documentid=100202307&page=1
A study
by Knudsen, et al., in the Journal of Psychoactive Drugs points out that over
49% of private substance abuse centers in both rural and urban areas claim they
use the Community Reinforcement Approach (CRA) as part of their overall
treatment program.
As
of April 1, 2008 Robert J. Meyers, Ph.D. has been awarded a new title by the
A new CRAFT article has been published in
the Journal Alcoholism Treatment Quarterly, Volume 26, Numbers 1/2, 2008. You can find it on pages 169-193. The title is Working with Family members to
Engage Treatment-Refusing Drinkers: The CRAFT Program. By Jane Ellen Smith, Ph.D., Robert J. Meyers,
Ph.D., & Julia L. Austin, MS. It
is available online at http://atq.haworthpress.com
Testimonial,
The substance of the ACRA
training has added value to the clinical structure of my agency as a whole, by
providing a way to define and organize clinical interventions and facilitating
clinical communication.
There is an added benefit to the ACRA model in its time-limited,
curriculum-oriented format which I think can do much to lower the barrier of
treatment acceptance by non-Western
populations. This is a problem that has troubled the addiction
treatment field for a long time.
Brandon Nguyen, LCSW,
Supervisor
Asian American Recovery Services Inc.
WHY USE A COMPREHENSIVE TRAINING MODEL
According to a recent national survey, 4.8 million
adults are in need of substance abuse services, but less than 1.5 million
receive them (Substance Abuse and Mental Health Services Administration, 2001).
Alarmingly, for those who do receive
treatment, all too often the interventions are not scientifically based
(Miller, Sorensen, Selzer, & Brigham, in press). In his most recent summary
of “What works?” in the alcohol treatment field, Miller again reported on
the striking negative correlation between empirically-supported treatments and
those treatments typically being used in the community (Miller, Wilbourne,
& Hettema, 2003 & 2005). Although there are numerous illustrations
of these overlooked evidence-based treatments, prime examples include
behavioral couples therapy (Fals-Stewart & Birchler, 2001), naltrexone,
contingency management (Carroll & Rounsaville, 2003), and the Community
Reinforcement Approach (Miller et al., 2003).
What are the reasons why practitioners do not commonly use the substance abuse
treatments with empirical backing? The range of obstacles varies widely,
beginning with clinicians simply being unaware of the effective treatments
(Fals-Stewart & Birchler, 2001), or thinking they actually are using scientifically-supported
treatments when, in fact, they are not (Erickson-Pritchard, 1999; Miller &
Meyers, 2001). Some clinicians are aware of the research findings, but question
the fact that the interventions were tested on carefully-screened non-diverse
samples (McLellan, 2002; Morgenstern, 2000), and while using unrealistically
standardized deliveries (Morgenstern, 2000). Another salient barrier is the
perceived clash in ideologies between scientists and many clinicians, with the
two “sides” differing in their fundamental tenets about the etiology of
substance abuse and the most basic components of treatment (McCrady, 1994;
Morgenstern, 2000). Practical obstacles to the adoption of empirically-based
interventions include the treatments being too difficult to learn or too boring
(Hayes, 2002), or the issue of counselors being too overworked and underpaid to
shoulder the responsibility of converting science into practice (Backer,
Liberman, & Kuehnel, 1986). Finally, despite many clinicians being open to
learning novel models, practice behavior that has been established for many
years is notoriously difficult to modify (Chapman & Chapman, 1967). What
does this suggest? We should examine the shortcomings in our standard training
of therapists, and develop approaches that would be more likely to yield and
maintain the desired behavior change.
Research
shows that dissemination efforts fall short if they focus exclusively on the clinicians’
behavior and do not take organizational (agency) factors into consideration
(Martin, Herie, Turner, & Cunningham, 1998; Simpson, 2002; Stirman,
Crits-Christoph, & DeRubeis, 2004). Models examining organizational change
suggest (on the basis of uncontrolled and case studies mostly) that leadership
attributes (e.g., risk tolerance), institutional resources, level of work
stress, clinical autonomy (Judge, Thoreson, Pucik, & Welbourne, 1999;
Simpson, 2002), compatibility between treatment philosophies (Thomas, Wallack,
Lee, McCarty, & Swift, 2003), affordability of programs for agencies and
insurance companies (Carroll & Rounsaville, 2003; McLellan, 2002; Thomas et
al., 2003), and a host of other factors have a non-trivial impact on adoption
practices. Consequently, in developing training programs in which eventual
adoption is truly an objective, we must be mindful of numerous critical factors
at both the individual and agency levels.
Given the limitations of the commonly used
one-time workshop to support the training and maintenance of new therapy
skills (Miller et al., 2004; Najavits et al., 2000), tape reviews and
supervision post-workshop is highly recommended.
Because
one would hope that an effective training strategy could be used there are
several things to consider. Thus, issues of affordability and availability
(e.g., to rural populations, to the disabled) must be examined. Although
offering the training via books/manuals satisfies these criteria, research does
not support the exclusive reliance on manuals as being an effective or
clinician-preferred method for either skills
acquisition (Levinson, Schaefer, Sylvester, Meland, & Haugen, 1982;
Miller et al., 2004; Sholomskas et al., 2005) or adoption (Sorensen et al., 1988). Importantly, the data further
suggest that one group of therapist, “recovering” counselors, performed better
in face-to-face trainings than when simply provided with CBT manuals
(Sholomskas et al., 2005). At the same
time, the most common format for continuing education training, a one-time
workshop or conference, has been shown to be problematic as well, particularly
for maintaining training effects
(Davis et al., 1999; Godley, White et al., 2001; Miller et al., 2004; Najavits
et al., 2000; VandeCreek, Knapp, & Brace, 1990).
Ongoing consultation during any transfer of
technology is considered critical
(Backer et al., 1986; McCarty et al., 2004; Simpson, 2002). Staying true to the
learning principle that gave rise to CRA, reinforcement appears to hold great
promise as far as the foundation of the supervision. Positive reinforcement for successive approximations
is a well-established principle of learning. Interestingly, Andrzejewski et al.
(2001) discovered that therapists’ practice behavior was highly responsive to
reinforcement, and thus he determined that the maintenance of new skills and
their use in the workplace appeared to be a motivational issue. For instance, one of the most consistent
findings in motivational psychology is that systematic feedback, when combined
and compared with behavioral goals, enhances performance (Locke & Latham,
1990). When a recent study evaluated the effect of supplying therapists with
objective feedback about their patients’
progress throughout therapy, it discovered that the clients of these
therapists showed twice the improvement rate of the clients of therapists who
received no such feedback (Lambert et al., 2001). Although the exact mechanism
of operation is unknown, one would assume that the therapists who received feedback modified their behavior in a
positive way. The same should apply to feedback about therapists’ own behavior.
In sum, we are left with the notion of supplying therapists with feedback about
their performance, thereby enhancing learning and reinforcing their behavior in
the process.
How can supervision that involves
feedback/reinforcement for new practice behavior best be offered? On a
practical note, the extremely high turnover rates of substance abuse staff
(including administrators) calls into question whether many agencies’
infrastructures could support some type of ongoing training themselves
(Fals-Stewart et al., 2004; McLellan, Carise, & Kleber, 2003).
Consequently, the supervision would likely need to occur with experts outside
of the agencies. The predicament of having to find therapist
training/supervision that is affordable, readily available regardless of
location, and of high quality leads one naturally to computers as the solution
(Weingardt, 2004).