A Systems Approach to Substance Abuse Treatment
Transcript
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