Paving the way: converting scientific research into substance abuse treatment methods
With over 27 years of combined experience, Dr Jaime Mulligan and Dr Ashli Sheidow from Training Support System (a division of Sheidow Consulting, Inc.) have dedicated their recent research to ensuring scientifically proven methods are translated into clinical practice. Their new web-based training and support system is paving the way for improved treatment outcomes for substance-abusing adolescents.
Despite significant recent advancements in drug abuse treatment methods, adolescent substance abuse remains a serious problem. The 2011 National Survey on Drug Use and Health found 7% of American youths between the ages of 12 and 17 met criteria for substance (illicit drug or alcohol) dependence or abuse.
A difficult path ahead
Although the issue of substance abuse is prevalent across multiple age groups, it presents specific risks and challenges in adolescents. Substance use in early teenage years is associated with higher levels of substance abuse and dependence later in life, often with deleterious effects on educational, social, physical, employment and mental health outcomes. Together, Mulligan and Sheidow have developed a new web-based system that is breaking new ground in counsellor training. The system provides training on a proven treatment method and delivers long-term support for counsellors to ensure that adolescents with substance abuse disorders receive effective treatment.
Best foot forward
Evidence-Based Practice (EBP) is a relatively new approach that has rapidly been gaining popularity and traction in the clinical world, and particularly in substance use treatment. EBP is widely defined as ‘the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences’ (Levant, 2005). In practice, an EBP approach uses treatment methods that have been found to have positive effects on patients’ progress in randomised clinical trials. As awareness of EBP spreads, these research-supported methods are being demanded not only by funding bodies and federal agencies but also by those individuals seeking treatment. EBPs are also gaining popularity from counsellors themselves, prompting research into how to ensure these treatments are delivered and sustained for optimum patient outcomes.
One such treatment method is Contingency Management for Youth Addiction (CM-YA) which combines behavioural and cognitive behavioural principles into a family treatment to target drug use. CM-YA is based on the principle that drug use is an operant behaviour and can therefore can be controlled by the individual with proper supports in place. Practically speaking, the principle of CM is that positive achievements such as negative urine tests or achievement of treatment goals are reinforced with immediate rewards such as vouchers or small cash prizes. CM has been found to have highly successful results in many studies, including those focused on youth addictions. For instance, Azrin et al (1994) used a randomised trial to compare CM-YA to supportive counselling, and found that youths receiving CM-YA were eight times more likely to abstain from drug use. Furthermore, CM-YA has been found to be safe to implement, produce positive outcomes across a range of addictions and work effectively alongside other available treatments (Carroll, 2004). In addition, community-based outpatient programmes currently provide the majority of substance use treatment. Due to its combination of behavioural therapy, cognitive behavioural therapy, and caregiver involvement, a CM-YA treatment model is particularly applicable to patients in this setting. This encouraging base of evidence has prompted Mulligan and Sheidow to focus on CM-YA treatment for their recent studies.
Contingency Management (CM) has been found to have highly successful results in many studies, including those focusing on youth addictions
A gap in the road
Despite the wealth of evidence supporting EBPs, and specifically CM-YA, it is clear that there are critical barriers between attaining knowledge and translating this knowledge into actual treatment practices. Although most practitioners support the use of EBPs, very few substance-use patients actually receive any evidence-based care. This gap between science and service can, in part, be attributed to the past stigmatisation of substance abuse issues, resulting in the development of treatments originating outside of mainstream healthcare. However, there are a range of additional factors that are inhibiting the uptake of EBPs in the modern medical world. Systemic barriers, such as cost and a lack of resources to learn a new EBP create practical obstacles in EBP uptake. Furthermore, personal barriers such as an unwillingness to accept that long-practised methods may not be best and resistance to change also play an important part. Alongside these factors, one of the key points to come out of numerous studies is that treatment models provide vastly improved clinical outcomes if they are delivered with fidelity (remain true to the model) and competency. This has served to shift the spotlight onto how best to train and monitor practitioners, alongside monitoring patient progress.
Bridging the gap
To overcome the barriers mentioned above, and thus deliver better patient treatment, Mulligan and Sheidow have developed the Training Support System (TSS) for CM-YA. The TSS for CM-YA is an entirely unique, web-based training and support platform that offers a cost-effective and accessible alternative to conventional training methods. Training and support are delivered in a three-tier design as detailed below:
1) Basic initial training in CM-YA is provided through the Contingency Management Computer Assisted Training (CM-CAT) that counsellors can complete at their own pace. This basic initial training includes a training companion toolkit and connects counsellors via the web with a Lead Trainer who monitors progress and provides 1:1 support, practice opportunities, and resources. Importantly, this web-based approach overcomes the financial burden faced by many community-based agencies and prevents scheduling and travel barriers. Additionally, it has proven to be popular with users: in a recent trial, 97% of people who completed the CM-CAT described it as “extremely helpful” and an increase in CM knowledge was observed following the training.
2) The second stage is the provision of ongoing feedback, Lead Trainer availability, and professional networking on both an individual and agency-wide level. Feedback relating to the understanding and use of CM-YA is provided through knowledge tests and coded session tapes. In addition, confidential monthly surveys from caregivers provide counsellor-specific and agency-wide feedback on adherence levels. These Key Performance Indicators are summarised quarterly in an implementation report provided to the counsellor and agency with recommendations for improving outcomes and adherence to the treatment model.
3) Training is sustained within the TSS with the availability of ongoing support and mentoring as well as access to up-to date literature and tools. A CM-YA expert Lead Trainer is assigned to each agency and, through this trainer, counsellors have access to resources, feedback and training that is tailored to their individual needs. This coaching can take multiple forms but may consist of elements such as web-based booster training sessions or role-play.
Thus, the TSS provides a training method that attends to all the possible barriers of dissemination, as well as providing comprehensive and ongoing support that continues well after the initial training is delivered. This will have vast positive implications for substance-abusing adolescents receiving treatment from practitioners trained through the TSS and sets a new level for how training methods can ensure both competency and fidelity.
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