A Systems Approach to Substance Abuse Treatment

Un Approccio Integrato ai Trattamenti per le
Tossicodipendenze
(A Systems Approach to Substance Abuse Treatment)
La flessibilità organizzativa nei dipartimenti delle
dipendenze - (The organizational readiness to
change of Veneto Region Drug Departements).
Dr. Dwayne Simpson & Dr. Pat Flynn
Texas Christian University (TCU)
Venice, Italy; 20-21 Sept 2004
Assessing Organizational Readiness for Change (Venice; 20 Sept 2004)
Assessing Organizational Readiness for Change (Venice; 20 Sept 2004)
A Systems Approach
to Substance Abuse
Treatment
Un Approccio Integrato
ai Trattamenti per le
Tossicodipendenze
Dwayne Simpson & Pat Flynn
Dwayne Simpson & Pat Flynn
TCU Institute of Behavioral Research
Fort Worth, Texas
TCU Institute of Behavioral Research
Fort Worth, Texas
1
Texas Horned Lizard
2
Treatment Funding in U.S.
Phrynosoma cornutum
Wash
DC
50 States
Private
Programs
The Texas Horned Lizard or "horny toad" is a flat-bodied
and fierce-looking lizard (3-4 inches long). The head has
numerous horns, with two central head spines being much
longer than any of the others. This lizard is brownish with
two rows of fringed scales along each side of the body.
Alcohol
?
Texas
Mental
Health
Public
Programs
Drug
Abuse
~ $1.4
Billion
Behavioral
Health Insurance
3
Drug Abuse Treatment Outcome Studies
4
Long-Term Residential (LTR)Treatment
Changes from Before to After Treatment
Third National Evaluation of Treatment Effectiveness in U.S.
100
Pre
DA
TO
S
Post
88
77
80
66
Funded by
the National
Institute on
Drug Abuse
Conducted
in 1990s
(over 85
studies)
60
41
40
40
22
20
24
19
17
16
13
6
10,000 Adults
96 Programs
11 Cities
www.datos.org
© 2004 TCU Institute of Behavioral Research,
Fort Worth, Texas. All rights reserved.
IBR Web site: www.ibr.tcu.edu
0
Cocaine
(Weekly)*
Heroin
(Weekly)*
Heavy
Alcohol*
Illegal
Activity*
No FT
Work*
Suicidal
Ideation*
*p<.001
% of DATOS Sample (N=676)
5
Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)
6
Page 1 of 6
Un Approccio Integrato ai Trattamenti per le
Tossicodipendenze
(A Systems Approach to Substance Abuse Treatment)
La flessibilità organizzativa nei dipartimenti delle
dipendenze - (The organizational readiness to
change of Veneto Region Drug Departements).
Dr. Dwayne Simpson & Dr. Pat Flynn
Texas Christian University (TCU)
Venice, Italy; 20-21 Sept 2004
Outpatient Drug-Free (ODF) Treatment
Outpatient Methadone Treatment (OMT)
Changes from Before to After Treatment
Changes from Before to After Treatment
100
Pre
Post
100
Pre
89
Post
85
82
76
80
82
80
60
60
42
42
40
40
31
25
22
18
15
20
15
20
11
9
29
28
22
19
14
0
16
17
14
13
0
Cocaine
(Weekly)*
Marijuana
(Weekly)*
Heavy
Alcohol*
Illegal
Activity*
No FT
Work*
Suicidal
Ideation*
Cocaine
(Weekly)*
Heroin
(Weekly)*
Heavy
Alcohol
Illegal
Activity*
No FT
Work
*p<.001
Suicidal
Ideation
*p<.001
% of DATOS Sample (N=764)
% of DATOS Sample (N=727)
Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)
7
Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997 (PAB)
8
Patient Retention Rates for Programs
(beyond minimum “thresholds”)
Best
Program
Worst
Program
65%
75%
Organizational Functioning
Funzionamento Organizzativo
Modello di Cambiamento?
----------------------------------------------Treatment Services
Servizi di Trattamento
76%
21%
16%
15%
3+ Mos in
Long-Term
Residential
(n=17)
3+ Mos in
Outpatient
Drug-Free
(n=14)
12+ Mos in
Outpatient
Methadone
(n=10)
Simpson, Joe, Broome, Hiller, Knight, & Rowan-Szal, 1997 (PAB)
Recovery Stages
and Treatment Services
Patient
Severity
Readiness
Early
Engagement
Early
Recovery
Program
Participation
Change:
Behavioral
Retention/
Transition
Modello TCU di Cambiamento del Personale
Training
motivazionale
Caratteristiche
del paziente
Supportive
Networks
Gravità
Motivazione al
cambiamento
Sufficient
Retention
Therapeutic
Change:
Relationship Psycho-Social
10
9
Strategie
comportamentali
Impegno
precoce
Abilità
interpersonali
e rete sociale
Guarigione
precoce
Ritenzione
Minima
Soglia
ritentiva
Crime
Relazione
terapeutica
Social
Relations
Posttrattamento
Reti di
sostegno
Partecipazione Cambiamento
al programma comportamentale
Drug
Use
Servizi di
Supporto sociale
Cambiamento
psicosociale
Uso di
sostanze
Criminalità
Relazioni
sociali
Posttreatment
Strategie
cognitive
Specialized interventions sustain this change process
Interventi specializzati sostengono questo processo di cambiamento
© 2004 TCU Institute of Behavioral Research,
Fort Worth, Texas. All rights reserved.
IBR Web site: www.ibr.tcu.edu
11
Training di abilità
interpersonali
Servizi
sanitari
Simpson, 2002 (La valutazione dell’outcome, Serpelloni, De Angeli, & Rampazzo)
12
Page 2 of 6
Un Approccio Integrato ai Trattamenti per le
Tossicodipendenze
(A Systems Approach to Substance Abuse Treatment)
La flessibilità organizzativa nei dipartimenti delle
dipendenze - (The organizational readiness to
change of Veneto Region Drug Departements).
Dr. Dwayne Simpson & Dr. Pat Flynn
Texas Christian University (TCU)
Venice, Italy; 20-21 Sept 2004
Induction to Treatment
Counseling Enhancements
(Training Motivazionale)
Patient
Severity
Readiness
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Patient
Retention/
Transition
Severity
Readiness
Sufficient
Retention
Therapeutic
Relationship
(Strategie Cognitive “Mapping”)
Psycho-Social
Change
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Retention/
Transition
Drug
Use
Sufficient
Retention
Crime
Therapeutic
Relationship
Social
Relations
Psycho-Social
Change
Drug
Use
Crime
Social
Relations
Posttreatment
Posttreatment
Impegno
precoce
13
Simpson & Joe, 1993 (Pt); Blankenship et al.,1999 (PJ); Sia, Dansereau, & Czuchry, 2000 (JSAT)
Contingency Management
Specialized Interventions
(Strategie Comportamentali)
Patient
Severity
Readiness
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
(Training di abilità interpersonali)
Patient
Retention/
Transition
Severity
Readiness
Sufficient
Retention
Therapeutic
Relationship
14
Dansereau et al., 1993 (JCP), 1995 (PAB); Joe et al., 1997 (JNMD); Pitre et al., 1998 (JSAT)
Psycho-Social
Change
Early
Engagement
Early
Recovery
Program
Participation
Behavioral
Change
Supportive
Networks
Drug
Use
Sufficient
Retention
Crime
Therapeutic
Relationship
Social
Relations
Psycho-Social
Change
+
Readiness
Interventions
Patient
Behavioral
Interventions
Early
Engagement
Severity
Program
Participation
Readiness
+
Training
motivazionale
Caratteristiche
del paziente
Supportive
Networks
Gravità
Behavioral
Change
Motivazione al
cambiamento
Sufficient
Retention
Therapeutic
Relationship
Bartholomew et al., 1994 (JPD); 2000 (JSAT); Hiller et al., 1996 (SUM)
Psycho-Social
Change
16
Modello TCU di Cambiamento del Personale
Social Skills
& Support
Early
Recovery
Posttreatment
15
Cumulative Impact of Interventions
Crime
Social
Relations
Posttreatment
Rowan-Szal et al., 1994 (JSAT); 1997 (JMA); Griffith, Rowan-Szal et al., 2000 (DAD)
Drug
Use
Strategie
comportamentali
Impegno
precoce
Abilità
interpersonali
e rete sociale
Guarigione
precoce
Ritenzione
Reti di
sostegno
Partecipazione Cambiamento
al programma comportamentale
Drug
Use
Minima
Soglia
ritentiva
Crime
Relazione
terapeutica
Social
Relations
Posttrattamento
Cambiamento
psicosociale
Uso di
sostanze
Criminalità
Relazioni
sociali
Posttreatment
+
Cognitive
Interventions
+
Strategie
cognitive
Recovery Skills
Training
Rowan-Szal, Chatham, Greener, Joe, Payte, & Simpson, in press (JMA)
© 2004 TCU Institute of Behavioral Research,
Fort Worth, Texas. All rights reserved.
IBR Web site: www.ibr.tcu.edu
17
Training di abilità
interpersonali
18
Page 3 of 6
Un Approccio Integrato ai Trattamenti per le
Tossicodipendenze
(A Systems Approach to Substance Abuse Treatment)
La flessibilità organizzativa nei dipartimenti delle
dipendenze - (The organizational readiness to
change of Veneto Region Drug Departements).
Dr. Dwayne Simpson & Dr. Pat Flynn
Texas Christian University (TCU)
Venice, Italy; 20-21 Sept 2004
Organizational Functioning
Funzionamento Organizzativo
----------------------------------------------Treatment Services
Servizi di Trattamento
www.ibr.tcu.edu
19
Organizational Functioning
20
Organizational Functioning
Climate:
• Mission
Patient
Severity
Readiness
Early
Engagement
Early
Recovery
Program
Participation
Change:
Behavioral
Program
?
Sufficient
Retention
Climate
Resources
Staff
• Cohesion
• Autonomy
• Communication
• Stress
• Change
Retention/
Transition
Therapeutic
Change:
Relationship Psycho-Social
Drug
Use
Program
Crime
Social
Relations
Resources:
• Offices/Staffing
• Training
• Equipment
Climate
Staff:
Resources
• Growth
• Efficacy
• Influence
• Adaptability
Staff
Motivation
Motivation
Motivation:
• Program Needs
• Training Needs
• Pressures
21
Climate: Cohesion of Staff
Funzionamento Organizzativo
(Scale scores range 10-50)
Clima:
• Mission
• Coesione
• Autonomia
• Comunicazione
• Stress
• Cambiamenti
Programma
Clima
Risorse
Personale
Motivazione
16
Lowest
Lowest 25%
25%
Norm
75%
Norm
50% of
Programs
Risorse:
• Uffici/Equipe
• Formazione
• Attezzature
22
Simpson, 2002 (J Substance Abuse Treatment)
Personale:
• Crescita
• Efficacia
• Influenza
• Adattabilità
Highest
25%
Motivazione:
• Necessità del servizio
• Necessità formative
• Pressioni a cambiamento
Simpson, 2002 (J Substance Abuse Treatment)
© 2004 TCU Institute of Behavioral Research,
Fort Worth, Texas. All rights reserved.
IBR Web site: www.ibr.tcu.edu
23
Highest
64 Programs (in Italy)
50
24
Page 4 of 6
Un Approccio Integrato ai Trattamenti per le
Tossicodipendenze
(A Systems Approach to Substance Abuse Treatment)
La flessibilità organizzativa nei dipartimenti delle
dipendenze - (The organizational readiness to
change of Veneto Region Drug Departements).
Dr. Dwayne Simpson & Dr. Pat Flynn
Texas Christian University (TCU)
Venice, Italy; 20-21 Sept 2004
Modello TCU di Cambiamento del Personale
Is patient progress
related to Organizational
Functioning?
Training
motivazionale
Caratteristiche
del paziente
Gravità
Motivazione al
cambiamento
I miglioramenti del paziente
sono correlati al
funzionamento organizzativo?
25
Strategie
comportamentali
Impegno
precoce
Abilità
interpersonali
e rete sociale
Guarigione
precoce
Ritenzione
Minima
Soglia
ritentiva
Clima
Risorse
Personale
Motivazione
Relazione
terapeutica
Cambiamento
psicosociale
Training di abilità
interpersonali
Strategie
cognitive
?
Interventi di
sistema
Posttrattamento
Reti di
sostegno
Partecipazione Cambiamento
al programma comportamentale
Caratteristiche
di programma
Servizi di
Supporto sociale
Uso di
sostanze
Criminalità
Relazioni
sociali
Servizi
sanitari
Simpson, 2002 (La valutazione dell’outcome, Serpelloni, De Angeli, & Rampazzo)
26
Program Change Model
Institutional &
Personal Readiness
How do Programs
Change?
Motivation
Resources
Stages of Change
Staff
1-Exposure
(Training)
• Lecture
• Self Study
• Workshop
• Consultant
Come cambiano
i programmi?
Climate
for Change
2-Adoption
(Leadership decision)
Program
Improvement
3-Implementation
(Services/Process/
Management)
(Exploratory use)
4-Practice
(Routine use)
Staff
Attributes
Organizational Dynamics
27
Program Change Model
Clima
organizzativo
To compare applications of new
assessments for organizational
functioning in the U.S. and Italy
Risorse
Gli Scopi del Progetto
Comparare le applicazioni dei recenti
strumenti di valutazione sul
funzionamento organizzativo
negli Stati Uniti e in Italia
Caratteristiche
del personale
Dinamiche organizzative
29
© 2004 TCU Institute of Behavioral Research,
Fort Worth, Texas. All rights reserved.
IBR Web site: www.ibr.tcu.edu
28
Project Goals
Disponibilità istituzionale
e personale
Motivazione
Simpson, 2002 (J Substance Abuse Treatment)
30
Page 5 of 6
Un Approccio Integrato ai Trattamenti per le
Tossicodipendenze
(A Systems Approach to Substance Abuse Treatment)
La flessibilità organizzativa nei dipartimenti delle
dipendenze - (The organizational readiness to
change of Veneto Region Drug Departements).
Dr. Dwayne Simpson & Dr. Pat Flynn
Texas Christian University (TCU)
Venice, Italy; 20-21 Sept 2004
Organizational Functioning
Funzionamento Organizzativo
ORC Scores for Programs in Italy vs. United States
Clima:
Needs
Staff Attributes
Organizational Climate
45
40
Risorse:
Personale
Motivazione
30
Personale:
25
• Crescita
• Efficacia
• Influenza
• Adattabilità
20
Small differences!
Italy (n=341)
U.S. (n=1089)
15
10
Motivazione:
• Necessità del servizio
• Necessità formative
• Pressioni a cambiamento
Simpson, 2002 (J Substance Abuse Treatment)
St
af
f
Tr
ai
ni
ng
ip
m
en
t
In
te
rn
et
G
ro
w
th
Ef
fic
ac
y
In
flu
en
ce
Ad
ap
ta
bl
e
M
iss
io
n
Co
he
s
Au ion
to
no
m
y
Co
m
m
St
re
ss
Ch
an
ge
Risorse
35
Eq
u
• Uffici/Equipe
• Formazione
• Attezzature
Clima
TCU Organizational Readiness for Change (ORC-S) Scores
31
32
Modello TCU di Cambiamento del Programma
Program Change Model
Disponibilità istituzionale
e personale
Disponibilità istituzionale
e personale
Motivazione
Resources
N
ee
ds
Tr
tN
ee
ds
Pr
es
su
re
O
ffi
ce
s
Programma
50
Pr
g
• Mission
• Coesione
• Autonomia
• Comunicazione
• Stress
• Cambiamenti
Motivazione
Risorse
Risorse
Accoglienza
e utilità
• Soddisfazione
• Facilità d’uso
• Conformità ai
valori
Fasi del cambiamento
Personale
2-Adozione
Decisione di leadership
1-Esposizione
3-Implementazione
Uso esplorativo
4-Pratica
Decisione di leadership
Miglioramenti
del programma
3-Implementazione
• Studio
• Workshop
• Consulenze
Uso esplorativo
(Servizi/Processi/
Organizzazione)
Caratteristiche
del personale
Clima
organizzativo
Caratteristiche
del personale
Dinamiche organizzative
Dinamiche organizzative
33
© 2004 TCU Institute of Behavioral Research,
Fort Worth, Texas. All rights reserved.
IBR Web site: www.ibr.tcu.edu
4-Pratica
uso abituale
uso abituale
Clima
organizzativo
2-Adozione
• Lezioni
(Training)
Supporti
istituzionali
• Monitoraggio
• Feedback
• Premi
Simpson, 2002 (La valutazione dell’outcome, Serpelloni, De Angeli, & Rampazzo)
34
Page 6 of 6