Clients: Screening and Intake
A major ingredient in achieving favorable treatment engagement and outcomes is the use of effective screening and assessment instruments to inform the treatment placement, planning, and decision-making process. When combined with collateral records (physical/mental health status, urine test results, arrest records), information gathered at admission from brief screens and lengthier clinical assessments can help to optimize treatment placement and identification of problems that can benefit from specialized interventions. Efficient and systematic data collection and management procedures are particularly important in view of the growing reliance on drug courts and correctional systems to address high-volume treatment needs of offender populations (see Knight, Flynn, & Simpson, 2008).
The TCU Drug Screen (Knight, Simpson, & Hiller, 2002) is a brief self-administered tool for DSM-IV classification of drug use and dependence, and it is widely used in correctional settings where offender assessment resources tend to be limited. Brief Intake and Comprehensive Intake interview instruments (Joe, Simpson, Greener, & Rowan-Szal, 2004) offer alternatives to other common assessments for obtaining detailed social background and drug-related information; several are customized for specific treatment settings. More customized versions can be created by selecting particular assessment domains represented in the TCU Core Forms. The Client Evaluation of Self and Treatment (CEST-Intake; Joe, Broome, Rowan-Szal, & Simpson, 2002; Garner, Knight, & Simpson, 2007) and the Criminal Thinking Scales (CTS; Knight, Garner, Simpson, Morey, & Flynn, 2006) are self-administered by clients and gauge their motivation for change and readiness for treatment, psychological and social functioning, and cognitive orientation towards criminal behaviors. They represent approximately 20 measures which can be re-administered over time to evaluate client changes during treatment.
Clients: Early Engagement and Recovery Progress
The first major step towards recovery in treatment is early engagement, which refers to the extent to which new admissions show up and actively engage in their role as a “client.” Engagement is measured operationally in terms of program participation and the formation of therapeutic relationships during the initial weeks of treatment. Evidence supports a sequential view of these components (Simpson & Joe, 2004); that is, clients with higher motivation at intake are at least twice as likely to participate in treatment (attend sessions and be “on-time”) in the first few months of treatment. In turn, clients showing higher levels of participation double their chances of developing a favorable therapeutic relationship with their counselor. While session attendance is generally required before clinical bonds are formed, it also is clear that participation and therapeutic relationships become interactive in the mutual strengthening of these early engagement components.
The second major step in treatment is early recovery, reflecting changes in thinking and acting that build on successes from the previous engagement stage. This also helps to sustain retention in treatment. Clients reporting stronger therapeutic relationships in treatment are more than twice as likely to show positive changes in psychosocial functioning as measured by self-esteem, depression, anxiety, risk-taking, social conformity, and decision-making (Simpson & Joe, 2004). Psychosocial functioning improvements, in turn, almost double the chances that favorable behavioral changes will follow (measured by urinalysis and self-reported drug use later in treatment). And not surprisingly, favorable behavioral changes significantly enhance the chances that clients will meet treatment retention expectations.
An expanded version of the Client Evaluation of Self and Treatment (CEST; Joe, Broome, Rowan-Szal, & Simpson, 2002; Knight, Garner, Simpson, Morey, & Flynn, 2006; Simpson, Rowan-Szal, Joe, Best, Day, & Campbell, 2009; Simpson, Joe, Knight, Rowan-Szal, & Gray, 2012) gauges client motivation for change and psychosocial functioning, along with additional scales for engagement (participation, therapeutic relationship, and treatment satisfaction) and personal support from peers and family. The CEST and the Criminal Thinking Scales (CTS) are designed for repeated applications to evaluate client progress throughout treatment. A variety of During Treatment Status interviews have provided details on many of the same client functioning domains addressed in the Intake forms, while Counseling Session Records and Services Tracking Reports capture details about specific services being delivered. Indicators of early recovery also can be addressed by Counselor Rating of Client. Several of the TCU Core Forms focus on these domains, and if collected both at intake and repeated at selected points during treatment they represent valuable monitoring and evaluation tools.
Clients: Retention and Re-entry
The third stage of treatment process, retention and re-entry transition, rests on the evidence that clients must remain in treatment long enough to stabilize and maintain recovery habits, especially before treatment discharge and social re-entry decisions are made (Simpson, 2004). This recognizes that successful transitions back into the community require a variety of health and social support services designed to address persistent mental health and social deficits. Barriers to client success increase in proportion to the history and severity of addiction-related problems, and the role of transitional services is viewed as being especially crucial for corrections-based treatment systems (Simpson, Knight, & Dansereau, 2004).
Discharge Reports are commonly used by programs to record date and circumstances related to treatment discharge. When medications are used as part of the treatment regimen for clients, routine medical files (such as “date of last medication”) likewise can provide reliable information for determining the likelihood of retention. Follow-up Interviews conducted on representative samples of clients, with a strategic protocol for scheduling interviews and carrying out fieldwork for locating former clients, can likewise provide useful information about treatment outcomes.
Staff: Program Needs and Functioning
There are widespread and growing pressures for behavioral health programs to adopt evidence-based practices. New research is showing, however, that this can be challenging because sequential steps should be followed for addressing organizational needs and readiness, preparation for change, decision making, and actions as part of an innovation implementation process. The TCU Program Change Model (Simpson, 2002; 2009; Simpson & Flynn, 2007) summarizes this process and provides a conceptual framework to help guide agencies in making practical decisions about initiating and managing innovation adoptions. In particular, findings show the importance of establishing early staff involvement and positive engagement in program-level changes. The overall quality of treatment programs depends on having not only an effective client-level service delivery plan (with integrated client assessments and interventions) but also a “healthy” staff environment in which services are delivered (Simpson & Dansereau, 2007).
The Program Training Needs (PTN; Rowan-Szal, Greener, Joe, & Simpson, 2007) survey of staff focuses on important domains of program needs and related issues (e.g., facilities, resources, staff training needs and preferences, and barriers for innovation adoption decisions). It is an abbreviated and efficient planning tool for programs that are beginning to explore organizational openness to innovations. It also helps staff feel they have been consulted about program needs and planning for treatment innovations, including the types of training needed. The PTN offers a preview of findings obtained from the more comprehensive Organizational Readiness for Change (ORC; Lehman, Greener, & Simpson, 2002; Greener, Joe, Simpson, Rowan-Szal, & Lehman, 2007) assessment which includes scales focused on staff perceptions of motivational pressures, resources, staff attributes, and organizational climate. User-friendly respondent feedback reports are highly recommended (see sample reports for the PTN and ORC). A companion to the ORC is the Survey of Organizational Functioning (SOF) which includes the ORC as well as nine additional scales measuring job attitudes and workplace practices.
Staff: Innovation Training and Adoption
Quality of training also is important in preparing counselors for change (Simpson & Flynn, 2007). Indeed, research shows that higher staff ratings on relevance of innovation training to client needs, along with the adequacy of program resource allocations, predict more successful use of innovations following training. Counselors face barriers in making changes in their clinical practice (such as lack of time and redundancy with current practices), but more positive staff-level responses to training and making progress in implementation are related to client reports of stronger therapeutic engagement.
The Workshop Evaluation (WEVAL) form (Bartholomew, Joe, Rowan-Szal, & Simpson, 2007) collects counselor ratings on relevance of the training, desire to obtain more training, and program resources supporting the training and implementation. The Workshop Assessment Follow-Up (WAFU) form (Bartholomew, Joe, Rowan-Szal, & Simpson, 2007) includes a section on post-training satisfaction, trial adoption of workshop materials, and an inventory about implementation barriers.