The development and validation of a transformational leadership survey for substance use treatment programs.

Directors in substance use treatment programs are increasingly required to respond to external economic and socio-political pressures. Leadership practices that promote innovation can help offset these challenges. Using focus groups, factor analysis, and validation instruments, the current study developed and established psychometrics for the Survey of Transformational Leadership. In 2008, clinical directors were evaluated on leadership practices by 214 counselors within 57 programs in four U.S. regions. Nine themes emerged: integrity, sensible risk, demonstrates innovation, encourages innovation, inspirational motivation, supports others, develops others, delegates tasks, and expects excellence. Study implications, limitations, and suggested future directions are discussed.

Program structure and counselor-client contact in outpatient substance abuse treatment.

OBJECTIVES: To examine organizational structural attributes associated with counselor-client contact. DATA SOURCES: Data were collected in 2004 and 2005 for a federally funded project, which simultaneously examines organizational structure, functioning, and resources among outpatient substance abuse treatment programs. STUDY DESIGN: The study uses a naturalistic design to investigate organizational structure measures-ownership, accreditation, and supplemental services-as predictors of time in counseling and case management, and caseload size, controlling for geographic differences. DATA COLLECTION: Directors at 116 outpatient drug-free treatment programs located in four regions across the U.S. (Great Lakes, Gulf Coast, Northwest, and Southeast) voluntarily completed a survey about program structure. PRIMARY FINDINGS: Clients received more counseling hours in programs that were "intensive," publicly owned, accredited, and had a lower proportion of recently hired counselors. More case management hours were offered in "intensive," private-for-profit or publicly owned (versus private-nonprofit) programs, serving a lower proportion of dual-diagnosis clients, and providing more on-site supplemental services. Smaller caseloads were found in programs that were accredited and had a smaller average client census and a lower proportion of criminal justice referred clients. CONCLUSIONS: Organizational attributes are related to counselor-client contact and may have implications for staff turnover and service quality.

Program structure, staff perceptions, and client engagement in treatment.

A key goal of drug abuse treatment providers is getting their clients to engage and participate in therapeutic activities as a first step toward deriving longer-term benefits. Much research had focused on personal characteristics that relate to client engagement; program characteristics have received less attention. This study explored client and program differences in engagement ratings using data from a nationwide set of 94 outpatient drug-free treatment programs in a hierarchical linear model analysis. The results show that elements of program context, including structural features (e.g., smaller size and Joint Commission on the Accreditation of Healthcare Organizations/Commission on Accreditation of Rehabilitation Facilities accreditation) and staff's perceptions of personal efficacy, organizational climate, and communal workplace practices, relate to better overall client engagement. These findings add further evidence that treatment providers should also address the workplace environment for staff as part of quality improvement efforts.

Counselor perceptions of organizational factors and innovations training experiences.

Because work environment is central to understanding job performance, drug counselor perceptions of their programs and their skills were examined in relation to their attitudes about innovations training and its utilization. Latent profile analysis of measures on organizational climate and staff attributes for 1047 counselors from 345 programs defined three categories of counselors-labeled as isolated, integrated, and exceptional. All had generally positive views of their professional skills, although the isolated group scored lower on scales representing professional growth and influence on peers. They were less positive about the "climate" of programs in which they worked and were higher on stress. Program resources predicted the counselor groups, with the isolated having more limited resources. Counselor categorizations also differed in terms of workshop training experiences, with the isolated group of counselors reporting significantly less exposure, satisfaction, and program-wide use of workshop training.

Patterns of drug use and expectations in methadone patients.

Expectations about future behavior have been shown to have a positive relationship with subsequent behavior. For patients in drug treatment, recovery should manifest changes in drug use and in cognitive perceptions of being able to refrain from use. The present study identified latent patterns of the longitudinal relationship between drug use expectation and illegal drug use during treatment. Latent variable mixture modeling identified three patterns of change over successive 3-month intervals during treatment: Improvers (48%), Decliners (33%), and Continuing Users (19%). The sample consisted of 497 patients in community-based outpatient methadone treatment. The utility of the latent patterns was shown through their relationship to treatment engagement, where Continuing Users had lower counseling rapport and time in treatment. These latent patterns also differed on drug use measures at follow-up. Additional analyses of expectations with measures of opioid use, cocaine use, or criminality yielded similar latent patterns. Expectations about future drug use were found to be a useful measure of cognitive change corresponding to drug use change. Its potential as a brief treatment management tool is noted.

A national 5-year follow-up of treatment outcomes for cocaine dependence.

BACKGROUND: Long-term (5-year) outcomes of community treatment for cocaine dependence were examined in relation to problem severity at treatment entry and treatment exposure throughout the follow-up period. METHODS: Interviews were conducted at 1 and 5 years after treatment for 708 subjects (from 45 programs in 8 cities) who met DSM-III-R criteria for cocaine dependence when admitted to treatment in 1991-1993. Primary outcome measures included cocaine use and arrests. Self-reported cocaine use showed high overall agreement with urine (79% agreement) and hair (80% agreement) toxicology analyses. RESULTS: Weekly cocaine use was reported by 25% of the sample at 5 years, slightly higher than the 21% at 1 year. Similarly, 26% had cocaine detected in urine specimens at follow-up and 18% reported having been arrested. Poorer long-term outcomes were related to higher problem severity at treatment admission and low treatment exposure. CONCLUSIONS: The large decreases in cocaine use 1 year after treatment discharge were sustained during the 5-year follow-up. Severity of drug and psychosocial problems at intake was predictive of long-term outcomes and outcomes improved in direct relation to level of treatment exposure.

Depression and hostility as predictors of long-term outcomes among opiate users.

AIMS: This study used data from the national Drug Abuse Treatment Outcome Studies (DATOS) to investigate the associations that pre-treatment depression and hostility have with drug use and criminal behavior at 1 year and 5 year follow-up in patients with and without additional treatment involvement in the year prior to each follow-up. DESIGN: Following a naturalistic, non-experimental evaluation design, admissions to methadone treatment were followed up approximately 1 and 5 years later. Data analysis was conducted using multiple logistic regression. SETTING: Eighteen programs from DATOS were included. PARTICIPANTS: An analytic sample consisting of 727 patients at 1 year follow-up and 432 patients at 5 year follow-up was included. FINDINGS: Multiple logistic regression analyses revealed that greater depression predicted less drug use in the year preceding each follow-up, whereas greater hostility predicted increased drug use and more arrests at each follow-up. Furthermore, these predictive relationships appeared only among individuals not involved in additional treatment. CONCLUSIONS: Depression and hostility showed opposite associations with outcomes, underscoring the need to assess these psychological conditions separately and tailor treatment plans appropriately.

Measuring patient attributes and engagement in treatment.

Brief but comprehensive instruments measuring patient motivation, psychosocial functioning, treatment process, social network support, and services received are needed for monitoring drug abuse treatment delivery and patient progress. Combining this information across patients within a program also provides useful indicators about institutional composition and functioning. Consequently, the same assessment tools can be used to identify areas where treatment protocols need to be changed, and to monitor improvements following such changes. The Texas Christian University (TCU) Client Evaluation of Self and Treatment (CEST)(1) is a 144-item self-rating instrument that includes 16 scales measuring patient functioning and treatment perceptions. Psychometric properties (including reliability and construct validity) of the scales are examined in this article, based on patient samples drawn from 87 programs that participated in a series of staff training workshops. Acceptable reliabilities (.70 or above) were generally reported, and construct validity was also demonstrated (although the confirmatory factor analyses suggested some item pools could represent more than one factor). Prediction analyses were conducted using selected scales from each measurement domain to illustrate their sensitivity to treatment program contexts.

Patient and program factors in obtaining supportive services in DATOS.

This study examined patient and program factors that influenced the receipt of scheduled supportive services in the Drug Abuse Treatment Outcome Studies (DATOS). Patients (N = 2,932) in 21 long-term residential (LTR) programs, 27 outpatient methadone treatment (OMT), and 25 outpatient drug-free programs were interviewed at admission and at 3 months during treatment. A hierarchical regression analysis was used to examine the relationship between patient-level and program-level factors associated with receiving supportive services in seven categories (medical, psychological, family, legal, educational, vocational, and financial). LTR patients received more services on average than outpatients (especially OMT), but patients overall received few services in the first 3 months of treatment. The patient-level likelihood of receiving services was related to being female and to having higher problem severity at intake. At the program level, outpatient clientele with higher problem severity received more services if they entered a program whose other enrolled patients were less troubled on average.

Recovery from opioid addiction in DATOS.

Patient attributions for their own long-term recovery were obtained in a 5-year followup of 432 admissions to 18 outpatient methadone treatment programs. Subjects were classified into two groups - recovering and non-recovering-strictly defined and based on both biological and self-report measures of no opioid or cocaine use, less than daily use of alcohol, and no arrests or illegal activity during the year prior to interview. The 28% who were in recovery at Year 5 reported that they had relied primarily upon personal motivation, treatment experiences, religion/spirituality, family, and their job/career. Particular value was placed on the support from family and close friends, indicating the importance of stronger efforts to develop social networks for support of drug-free functioning, especially among patients who lack these resources or need them strengthened. More information is available on the Internet at www.ibr.tcu.edu.

Exploring and reducing stress in young restaurant workers: results of a randomized field trial.

PURPOSE: Young adult restaurant workers face the dual stressors of work adjustment and managing personal responsibilities. We assessed a new psychosocial/health promotion training designed to reduce these stressors in the context of restaurant work. DESIGN . A cluster-randomized trial of a training program, with surveys administered approximately 2 weeks before training and both 6 and 12 months after training. SETTING: A national restaurant chain. SUBJECTS: A total of 947 restaurant workers in 28 restaurants. MEASURES: Personal stress, exposure to problem coworkers, and personal and job characteristics. INTERVENTION: Team Resilience (TR) is an interactive program for stress management, teamwork, and work-life balance. TR focuses on "five Cs" of resilience: compassion, commitment, centering, community, and confidence. ANALYSIS . Mixed-model (multilevel) analysis of covariances. RESULTS: Compared with workers in control stores, workers in TR-trained stores showed significant reductions over time in exposure to problem coworkers (F[2, 80.60]  =  4.48; p  =  .01) and in personal stress (F[2, 75.28]  =  6.12; p  =  .003). CONCLUSION: The TR program may help young workers who face the challenges of emerging adulthood and work-life balance.

Treatment program operations and costs.

This study investigates how average costs for an episode of care in outpatient drug-free (ODF) treatment relate to clinical intensity (length of stay and weekly counseling hours) and program structure (e.g., size, staffing), controlling for prices paid and selected clientele measures. Based on cost assessments from a naturalistic sample of 67 programs located across the United States (using the Treatment Cost Analysis Tool), robust regression techniques showed that programs having 10% longer treatment stays had episode costs 7% higher; those having 10% more weekly counseling hours per client had 4% higher episode costs. Other important factors included wages, amount of counselors' time conducting sessions, and serving more clients referred from the criminal justice system. The study provides valuable information on treatment program features that relate to costs. Most importantly, cost differences associated with longer stays or more intensive counseling protocols appear modest and may be justified by improved client outcomes.

Reducing heavy alcohol consumption in young restaurant workers.

OBJECTIVE: Restaurant employees often have high rates of heavy drinking and problems with alcohol. This study evaluates reductions in drinking and associated problems at work, in connection with a new program for prevention and early intervention. The program, called Team Resilience, is designed for young restaurant workers. METHOD: A cluster-randomized trial design was used, with 28 stores from a national casual-dining restaurant chain and 235 of their employees (54% male, 46% female). Fourteen stores received the Team Resilience training workshop, consisting of three 2-hour sessions held on 3 consecutive days. Sessions included group discussion, role-play and practice activities, and a learning game. RESULTS: Workers in trained stores reported significantly greater decreases in recurring heavy drinking (i.e., having five or more drinks on the same occasion, on 5 or more days in the past month) and work-related problems with alcohol than workers in control stores. In the intervention group, the odds of recurring heavy drinking declined by about one half and the number of work-related problem areas declined by one third following training. In addition, drinking behaviors and problems were tied to age and were most common among employees in their middle 20s. CONCLUSIONS: Findings support Team Resilience as an effective intervention for reducing drinking and associated problems among young restaurant workers, a population with substantial needs.

Supervisory turnover in outpatient substance abuse treatment.

Staff turnover is a significant issue within substance abuse treatment, with implications for service delivery and organizational health. This study examined factors associated with turnover among supervisors in outpatient substance abuse treatment. Turnover was conceptualized as being an individual response to organizational-level influences, and predictors represent aggregate program measures. Participants included 532 staff (including 467 counselors and 65 clinical/program directors) from 90 programs in four regions of the USA. Using logistic regression, analyses of structural factors indicated that programs affiliated with a parent organization and those providing more counseling hours to clients had higher turnover rates. When measures of job attitudes were included, only parent affiliation and collective appraisal of satisfaction were related to turnover. Subsequent analyses identified a trend toward increased supervisory turnover when satisfaction was low following the departure of a previous supervisor. These findings suggest that organizational-level factors can be influential in supervisory turnover.

A web-based approach to address cardiovascular risks in managers: results of a randomized trial.

OBJECTIVES: To examine whether a Web-based health and leadership development program--designed specifically for managers--was associated with changes in self-reported and biometric indicators of cardiovascular disease within the context of a randomized control trial. METHODS: A total of 145 managers from 8 organizations participated in a 6-month Internet-based program or a control condition. They completed pre- and posttest assessments that included both self-reported attitudes (on diet, exercise, and mental health) and biometric measures (eg, body weight, waist circumference). RESULTS: The intervention was associated with improvements in dietary attitudes, dietary self-efficacy, and exercise, and reductions in distress symptoms. Women in the program reduced their waist circumference significantly more than controls. CONCLUSIONS: The program showed promise for reducing cardiovascular disease risk factors. Similar results across diverse organizations suggest the program may be useful across industry types.

Leadership, burnout, and job satisfaction in outpatient drug-free treatment programs.

Counselors are a critical component of substance abuse treatment programming, but their working experiences are not yet well understood. As treatment improvement efforts focus increasingly on these individuals, their perceptions of program leadership, emotional burnout, and job satisfaction and related attitudes take on greater significance. This study explores counselor views and the impact of organizational context using data from a nationwide set of 94 outpatient drug-free treatment programs in a hierarchical linear model analysis. Results show counselors hold generally positive opinions of program director leadership and job satisfaction and have low levels of burnout, but they also have important variations in their ratings. Higher counselor caseloads were related to poorer ratings, and leadership behaviors predicted both satisfaction and burnout. These findings add further evidence that treatment providers should also address the workplace environment for staff as part of quality improvement efforts.

Treatment Cost Analysis Tool (TCAT) for estimating costs of outpatient treatment services.

A Microsoft Excel-based workbook designed for research analysts to use in a national study was retooled for treatment program directors and financial officers to allocate, analyze, and estimate outpatient treatment costs in the U.S. This instrument can also be used as a planning and management tool to optimize resources and forecast the impact of future changes in staffing, client flow, program design, and other resources. The Treatment Cost Analysis Tool (TCAT) automatically provides feedback and generates summaries and charts using comparative data from a national sample of non-methadone outpatient providers. TCAT is being used by program staff to capture and allocate both economic and accounting costs, and outpatient service costs are reported for a sample of 70 programs. Costs for an episode of treatment in regular, intensive, and mixed types of outpatient treatment were $882, $1310, and $1381 respectively (based on 20% trimmed means and 2006 dollars). An hour of counseling cost $64 in regular, $85 intensive, and $86 mixed. Group counseling hourly costs per client were $8, $11, and $10 respectively for regular, intensive, and mixed. Future directions include use of a web-based interview version, much like some of the commercially available tax preparation software tools, and extensions for use in other modalities of treatment.

The role of social support following short-term inpatient treatment.

The intensive, time-limited, short-term inpatient modality treatment for substance abuse appears to have positive outcomes despite its brevity. This study examined patient characteristics and posttreatment experiences to understand who is likely to benefit from this treatment and under what circumstances. Our sample included 748 patients in 12 short-term inpatient programs. Twenty-two percent of patients used cocaine at least weekly in the 1-year follow-up period, and an additional 9% drank frequently (compared with pretreatment rates of 69% and 15% respectively). Overall, patients' social support networks following treatment were more important factors than the pre- or during-treatment variables examined.

Looking back on cocaine dependence: reasons for recovery.

Factors that contributed to long-term recovery from cocaine dependence were examined as part of a 5-year national follow-up study of 708 patients from 45 treatment programs in eight U.S. cities. Outcomes from 33% of the sample were highly favorable at follow-up, including no drugs detected in urine or hair specimens, no self-reported use of any drugs, less than daily alcohol use, and no illegal activity or arrests during the past year. Major reasons cited for these improvements were motivations to change, positive influences of family, strength from religion and spirituality, and help from drug treatment. "Recovery" was viewed as a continuous process and one that benefits from lessons learned in treatment. These retrospective attributions affirm many of the same findings from prospective outcome studies and contribute to a conceptual framework for treatment process and recovery.