The University of Georgia Evidence-Based Treatment Practices in Adolescent Substance Abuse Treatment Programs: Data from the Public and Private Sectors Hannah K. Knudsen, Ph.D. Center for Research on Behavioral Health and Human Services Delivery The University of Georgia SAPRP Project 053130 The University of Georgia

The University of Georgia Project Significance Adolescent substance abuse is a significant public health problem Treatment can improve outcomes Historically, adolescents were integrated into adult programs, which ignored the unique needs of youths CSAT now advocates the separation of adolescent and adult services “Adolescent-only” care is a necessary, but not sufficient, condition of evidence-based treatment There are few data on the adoption and implementation of evidence-based treatment practices (EBPs) within adolescent-only programs The University of Georgia

The University of Georgia Research Design Builds on NIDA-funded research of nationally representative samples of publicly funded & privately funded SATx centers Use of telephone screening to identify eligible programs Must admit clients 18 years or younger Must offer at least one treatment program that is “adolescent-only” Programs can be outpatient, inpatient and/or residential A high percentage of centers either do not admit or do not have an adolescent-only level of care (~60%) Primary data collection via telephone interviews with adolescent program managers Current sample size is 128 centers The University of Georgia

Adolescent-Only Levels of Care The University of Georgia

Program’s Treatment Model The most common treatment model was described as “eclectic/mixed” These programs drew on elements from multiple models Few centers relied only on a 12-step model The University of Georgia

Individualized Treatment Plans Individualized treatment plans have been nearly universally adopted Program managers were asked about the extent (0 = none, 5 = a great deal) that the plan is tailored to take into into account the characteristics of the client Although plans were highly likely to take into account SA and MH needs, treatment plans were less likely to take into account demographic characteristics The University of Georgia

Adoption of Psycho-Social EBPs in Adolescent Treatment The University of Georgia

Treatment Fidelity: CBT “Thinking about how CBT is used at this center, to what extent does the delivery emphasize the following…” Mean 0 = not at all emphasized 5 = heavily emphasized The use of functional analysis to identify clients’ thoughts and feelings before and after substance use. 3.84 The identification of triggers of substance use 3.75 Routine discussions of encounters with “high risk” situations for substance use and the coping skills used in those situations 4.73 The use of role-playing to learn new skills 3.55 The assigning of homework to practice new skills 3.61 The development of concrete strategies for coping with craving 4.26 Learning drug refusal skills 4.41 Creating an “all purpose coping plan” of emergency contacts, safe places, and reliable distracters 4.29 Developing problem-solving skills 4.54 Scale properties: One-factor solution with a = .81 4.22 (SD=.54) The University of Georgia

Treatment Fidelity: MET/MI “Thinking about how Motivational Enhancement Therapy/Motivational Interviewing is used at this center, to what extent does the delivery emphasize the following…” (0 = not at all emphasized to 5 = heavily emphasized) Mean (MET-Concordant Factor) (MET-Discordant Factor) Assessing clients with regard to the five stages of change 3.89 Confronting clients about their substance-related problems 4.06 Encouraging clients to evaluated how their behaviors are different from their goals and ideals 4.37 Allowing clients to compare the costs and benefits of continuing or stopping their substance abuse 4.30 Exploring the areas in the which clients want to achieve change 4.41 Avoiding the use of argumentation with clients 4.24 Expressing support for the client’s ability to succeed 4.68 The use of reflexive listening Encouraging clients to develop their own “change plan” with goals and plans for dealing with barriers to those goals 4.23 Confronting clients about resistance 3.79 Scale Properties: Two-factor solution with MET-Concordant a = .84 and MET-Discordant a = .69 4.27 (SD=.68) 3.92 (SD=.98) The University of Georgia

Treatment Fidelity: Brief Strategic Family Therapy “Thinking about how Brief Strategic Family Therapy is used at this center, to what extent does the delivery emphasize the following…” Mean 0 = not at all emphasized 5 = heavily emphasized Building therapeutic alliances with the adolescent as well as family members 4.26 Gaining the trust of the family members as a foundation for the change process 4.32 Including the entire family in the treatment process 3.94 Assessing patterns of family communication and interaction that contribute to the adolescent’s drug use 4.34 The use of behavioral contracting to set clear ground rules for family interactions 3.74 Having family members speak directly to each other rather than recounting events to the therapist 4.11 Developing appropriate boundaries between family members that avoid enmeshment and reduce disengagement 4.21 Empowering parents to be the leaders of the family 4.36 Reframing negativity expressed by the client and/or family members Scale properties: One-factor solution with a = .90 4.18 (SD=.74) The University of Georgia

The University of Georgia Continuing Care Plans Nearly all centers (92.0%) report that a continuing care plan is developed for all of their adolescent clients Those plans sometimes include contact via telephone counseling, but rarely include home-based counseling The University of Georgia

The University of Georgia Summary Adolescent treatment programs largely deliver outpatient care using either an eclectic or CBT-based model Several psycho-social EBPs have been widely adopted, including CBT, motivational interviewing, and motivational enhancement therapy Motivational incentives (contingency management) and Brief Strategic Family Therapy are less common, but have been adopted by about one-third of programs Among adopters, CBT and BFST appear to be largely implemented with fidelity However, MET/MI-adopting centers continue to use confrontational approaches, which are not consistent with MET/MI Treatment plans and continuing care plans have been adopted There is variability in 1) the extent to which treatment plans are tailored and 2) the use of telephone & home-based counseling as part of continuing care The University of Georgia