the university of georgia challenges for the modern tc: balancing tradition with the demands of...

The University of Georgia

Challenges for the Modern TC: Balancing Tradition with the

Demands of Today’s Health Care System

J. Aaron JohnsonHannah K. Knudsen

Meredith H. Dye

This research is supported by NIDA Research Grants R01DA13110, R01DA14482, & R01DA14976


Major Challenges for Today’s Therapeutic Community

• Staffing Issues– Staff burnout/turnover– Development/training of existing staff– Transition to professionally trained workforce

• Clinical Services– Reduction in lengths of stay– Adaptation of TC model to outpatient tx

• Client Mix– Modification of model to fit client needs– Women/children programming


The National Treatment Center Study:

An Overview


Key Goals of the NTCS

• To document the range of treatment services available in the American substance abuse treatment system– Levels of care, use of medications, types

of therapies, wraparound services

• To understand issues related to workforce retention, including both counselors and program leaders


Types of Treatment Organizations

in the NTCS• This presentation focuses on:

– Publicly funded programs– Privately funded programs– Therapeutic communities (TCs)

• Centers affiliated with NIDA’s Clinical Trials Network also part of NTCS, but not included in these analyses

• Recently we added methadone programs, but data are not yet available for analysis


Public Centers• Nationally representative sample of 362

public centers– 80% response rate

• Eligibility for study defined by funding sources:– > 50% of revenues from government

grants/contracts– Includes government-owned facilities and

non-profit programs that rely on public funding

– Average center receives 84% of its funding from public sources


Private Centers

• Nationally representative sample of 403 private centers– 88% response rate

• Eligibility for study defined by funding sources:– < 50% of revenues from government

grants/contracts– Includes for-profit facilities and non-profit

programs that rely on private funding (e.g. insurance, self-paying clients)

– Average center receives less than 20% of its funding from public sources


Therapeutic Communities

• Nationally representative sample of 380 TCs– 83% response rate

• Programs only required to identify themselves as TCs– Captures the spectrum of programs that report

using this treatment model– Interviews include measures such as De Leon’s

“Essential Elements” and membership in Therapeutic Communities of America to see how closely programs adhere to the classic TC models


Types of Programs NOT in the NTCS

• Programs based in correctional settings

• VA programs• Halfway houses & transitional

housing• DUI services• Counselors in private practice


Basic Research Methods

• Data collected from mid-2002 to early 2004• Three levels of data collection

– Organizations Face-to-face interviews with administrators & clinical

directors Organizational structure, availability of services, staffing

– Leaders Mailback questionnaire Leadership style, organizational strategy, burnout,

turnover intention, demographic characteristics– Counselors

Mailback questionnaire Job characteristics, attitudes toward innovations,

burnout, turnover intention, demographic characteristics


Data Sources• Intensive onsite interviews with

administrators and clinical directors in nationally representative samples of public and private centers and therapeutic communities

• Mail questionnaires distributed to counselors in all participating centers– (Response rate >60% across all three types

of centers)– Total Counselor Sample Size = 31211198 Public, 1084 Private, 1043 TC counselors


Therapeutic Communities:Organizational Characteristics


TC Ownership & Profit Status

Ownership:• Private Foundation 29.4%• Board of Directors 26.0%• 503(c) non-profit corporations 24.4%• Government Owned 8.5%• Hospital <1%• Individual 6.6%• Religious Order 4.0%• University <1%

Only 8.7% of the sample operate as for-profit organizations


Distribution of TC Age

10.1%

15.6%

30.3%

20.2%23.8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

0-5

year

s

6-10

yea

rs

11-2

0 ye

ars

21-3

0 ye

ars

>30

year

s


Organizational Size in FTEs

35.6%

44.9%

19.5%

0%

10%

20%

30%

40%

50%

1-10

FTE

s

11-3

0 FTEs

> 30

FTEs


Residential Treatment in TCs

• 89.2% offer at least one residential level of care– 27.9% only offer long-term residential programs– 25.5% only offer short-term residential programs– 35.8% offer a mixture of residential & outpatient

programs

• 10.8% only offer outpatient levels of care


Client Characteristics: Primary Diagnosis

33.9%

18.4%

34.6%

0%

25%

50%

Cocaine Opiates Alcohol

• Administrators were asked about the distribution of their TC’s caseload by primary diagnosis

• The average for cocaine & alcohol were similar


Client Characteristics: Demographic Characteristics

38.8%

51.7%58.4%

0%

25%

50%

75%

100%

% Women % Minority

% Court-Involved

• Administrators were asked to describe the demographic characteristics of the TC’s caseload


Staffing the Modern TC


The Addiction Workforce:Characteristics of Counselors


Research Questions

• What is the current composition of the TC counselor workforce in terms of basic demographics, education, certification, and training?

• How do TC counselors compare to other counselors in the substance abuse treatment field?

• What is the potential impact of these differences on TCs in terms of counselor burnout/turnover, service delivery, etc.?


DescriptivesPublic Private TC

% Female 64.0 a 57.9 60.1

Age 44.5 46.4 43.6

% White 64.2 a,b 82.2 c 56.0

% Af. Am. 22.5 a,b 10.2 c 29.4

% Hispanic 7.9 a,b 3.4 c 8.8

% Recovery 50.8 b 52.9 c 57.0a = Public/Private sig. different; b = Public/ TC sig. different; c = Private/ TC sig. different


Counselor Salary

0

10

20

30

40

50

25K or less 25K to 35K 35K to 45K MT 45K

TC Public Private

• TC counselors have sig. lower salaries than both public and private programs


Counselor Credentials,Training and Experience


Counselor Education

0

10

20

30

40

50

HS or Less Some Coll College MA/Higher

TC Public Private

% of counselors w/ college degrees almost = across all three types of programs.

% MA or higher counselors sig. higher in public and private programs


Counselor Certification/Licensure

45.353

59.2

18.123.9 27.6

0

10

20

30

40

50

60

Certified Licensed

TC Public Private

• A significantly lower percentage of TC counselors have obtained certification and/or licensure


Hours of Training: Within and Outside Program

32.9

23.720.6

33

44.9

36.8

05

1015202530354045

Within Outside

TC Public Private

• TC counselors receive significantly more “in-service” training hours than non-TC counselors

• Sig. higher % of TC counselors report receiving 0 hours of outside training (18.9% vs. 11% and 12% for public and private programs)


Counselor Tenure at Center/Tenure in Field (In Years)

4.2 4.7 5.5

7.3 8.3

10.3

0

2

4

6

8

10

12

Yrs at Ctr Yrs in Field

TC Public Private

• TC counselors sig. fewer yrs at center and fewer years in field than non-TC counselors

• All are sig. below average US workforce (8.4 yrs)


Counselor Turnover in Addiction Treatment Programs

• Previous research shows annual turnover rates range from 18% to 50% (Gallon et al., 2003; Johnson et al, 2002; McLellan et al, 2003).

• Current data shows range between 13% and 21% depending on type of program

• Significantly higher than national average across all occupations (11%)

• Higher than teachers (13%) and nurses (12%) – occupations known for high turnover


Comparing Voluntary Turnover

21

13.1

20.5

0

5

10

15

20

25

Public Private TC

Public Private TC

• Public centers and TCs have significantly higher turnover than private centers (p<.001)


What do we know about the differences between these types of programs that might explain

differences in counselor turnover?


Private Centers vs. Public Centers and Therapeutic Communities (TCs)

Private centers– Higher % with primary alcoholism diagnosis– Counselors have higher levels of education

and/or certification– Higher average salaries

Public centers and TCs– Higher % relapsers and CJ referrals– Higher % minority clients– Higher % with primary cocaine diagnosis– Higher % minority counselors


Results

• Higher levels of turnover associated with:– For profit status– Larger capacity– Composition of workforce– Prior Turnover Rate

• Lower levels of turnover associated with:– Counselor-management relations– Counselor-supervisor relations


Explanation of Results – Workforce Composition

• Aspects of workforce affecting turnover– Higher percentage of female

counselors = higher turnover– Higher percentage of counselors in

recovery = higher turnover– Higher percentage of minority

counselors and counselors certified in addictions = lower turnover


Explanation of Results –Counselor-management relations

• Job autonomy• Participative management

– Effective channels of communication between employees/management

– Actively involving employees in decision-making, particularly about their own jobs

• Performance based rewards– center rewards hard work with recognition, promotions– The amount of recognition I receive when I do a good

job is satisfactory– If I perform my job well, I am more likely to be

promoted


Explanation of results – counselor/supervisor relations

• Effective Supportive Clinical Supervision– Supervisor can provide good advice

because of his/her expertise and training

– Supervisor does provide work-related advice that improves the counselor’s ability to treat clients


How exactly does this reduce turnover?

• Increased Organizational Commitment– Willing to put in extra effort to help center

succeed– Proud to tell others I am part of this center– This is best of all possible centers for which

to work– Employees will be more committed to the

organization if they feel that the organization is committed to them - The norm of reciprocity


How does this reduce turnover? (cont.)

• Reduced levels of burnout/emotional exhaustion– “I feel emotionally drained from my

work.”– “I feel frustrated by my job.” – Certain jobs at higher risk of burnout,

particularly those that involve “constantly dealing with other people and their problems” (Cordes & Dougherty, 1993)


What doesn’t impact turnover?

• The diversity of services offered• Counselor education level• Counselor salaries• The types of patients being treated

– Relapsers, CJ Clients, Indigent, Specific drugs


Take Home Message

• Turnover breeds turnover – programs with high rates have a difficult time reducing turnover

• Difficult clients are not the issue• Money is not the issue - Increasing counselor

salaries will not reduce turnover• The lowest turnover rates are in programs that

successfully create a smaller “family” type culture in which counselors feel that they are able to communicate with management and are included in important decisions. The result is a workforce committed to the program and willing to work hard to see it succeed.


Service Comprehensiveness in Addiction Treatment

Hannah K. Knudsen, Ph.D.


Service Comprehensiveness in the Context of Evidence-Based

Treatment• In 2000, the National Institute on Drug

Abuse published its Principles of Drug Abuse Treatment

• Comprehensive treatment as consisting of two domains:– Core addiction services– Wraparound services

• Together, core and wraparound services represent a model of service comprehensiveness that should improve client outcomes


Conceptualizing Service Comprehensiveness

• Treatment programs can be described in terms of:– The availability of each service– The number of core services offered– The number of wraparound services

offered– Service comprehensiveness as the total

number of core and wraparound services


Research Questions

• How do TCs compare to non-TCs in terms of provision of specific core & wraparound services?

• Do TCs provide more core & wraparound services than non-TCs?

• Is there a difference in overall service comprehensiveness between TCs and non-TCs?


Data• Three nationally representative samples• 380 self-identified therapeutic communities• 363 publicly funded non-TC centers

– Receive >50% funding from government block grants/contracts

• 403 privately funded non-TC centers– Received <50% funding from government block

grants/contracts

• Data collected via face-to-face interviews with administrators and/or clinical directors– Interviews conducted between late 2002-early 2004– Use of identical measures across 3 samples allows

for comparisons


Are there differences between TCs and other programs in the availability of core addiction

services?


Core Addiction Services

• Assessment• Behavioral therapy and counseling

(individual and group)• Substance use monitoring• Pharmacotherapy• Self-help/Peer support groups• Continuing care


Assessment: Use of the ASI

• The Addiction Severity Index (ASI) is an assessment instrument that has been validated in many research studies

• Some states mandate the use of the ASI• % of Programs Using the ASI:

– TCs: 55.1%– Public Non-TCs: 59.0%– Private Non-TCs: 36.7%

• TCs are significantly more likely than privately funded non-TCs to use the ASI


Strong Emphasis on Individual and Group Therapy

78%69%

57%

0%

50%

100%

Individual Therapy

TC Public Private

• TCs are significantly more likely to place a strong emphasis on individual therapy than public & private programs

• No differences for group therapy

88% 85% 85%

0%

50%

100%

Group Therapy

TC Public Private


Substance Use Monitoring:Drug Testing During Treatment

98.9%

92.8%95.3%

0%

50%

100%

Drug Testing

TC Public Private

• The vast majority of programs use some form of drug testing during treatment

• TCs are more likely to use drug testing than public & private programs


Pharmacotherapy

16.5%24.1%

54.0%

0%

50%

100%

AnyPharmacotherapy

TC Public Private

• Centers were categorized based on use of any FDA-approved addiction medications (disulfiram, naltrexone, methadone, and/or buprenorphine)

• TCs are less likely to use pharmacotherapy than private programs

• Difference between TCs and public programs approaches significance (p<.06)


Self-Help/Peer Support Groups

72.5%

59.5%66.9%

0%

50%

100%

12-Step Groups

TC Public Private

• Any 12-step groups hold meetings at the center

• TCs are more likely to hold 12-step meetings at the program than publicly funded programs


Continuing Care/Aftercare

48.9%

57.5%63.1%

0%

50%

100%

Aftercare Program

TC Public Private

• Center offers aftercare program

• TCs are less likely to offer aftercare than privately funded programs

• Difference between TCs and public programs approaches significance (p<.06)


Comprehensiveness ofCore Addiction Services

4.554.46

4.57

0 1 2 3 4 5 6 7

Private Public TC

• Comprehensiveness of core addiction services as number of services offered

• No significant differences by center type


For core services…

• There were no differences across the samples in the average number of core services offered

• But there were differences in availability of specific core services– TCs higher on ASI for assessment,

individual therapy, drug testing, & 12-step groups

– TCs lower on pharmacotherapy & aftercare


Are there differences between TCs and other programs in the

availability of wraparound services?


Wraparound Services

• Medical services• Mental health services• Family services• Childcare• Transportation assistance• Legal services• Employment-related services• Financial services


Medical & Mental Health Services

58% 53% 52%

0%

50%

100%

Medical Services

TC Public Private

• No differences between centers in medical services

• TCs are less likely to provide integrated care for co-occurring MH and substance abuse disorders, relative to privately funded programs

51% 50%65%

0%

50%

100%

Integrated MH Care

TC Public Private


Family-Related & Childcare Services

66%55% 55%

0%

50%

100%

Family Program

TC Public Private

• TCs are more likely than public and private programs to provide services that address family-related problems

• TCs are more likely to offer childcare for clients with children than privately funded programs– Difference between TCs

and public centers approached significance (p<.06)

23% 28%

8%0%

50%

100%

Childcare

TC Public Private


Transportation and Legal Services

85%71%

53%

0%

50%

100%

Transportation

TC Public Private

• Compared to public and private centers, TCs are more likely to offer services that provide assistance with:– Transportation– Legal problems

52%36% 25%

0%

50%

100%

Legal Services

TC Public Private


Employment and Financial Services

49%37%

23%0%

50%

100%

Employment Services

TC Public Private

• Compared to public and private centers, TCs are more likely to offer services that provide assistance with:– Employment needs– Financial problems

36% 28% 20%0%

50%

100%

Financial Services

TC Public Private


Comprehensiveness ofWraparound Services

2.993.53

4.18

0 1 2 3 4 5 6 7

Private Public TC

• Comprehensiveness of wraparound services as number of services offered

• TCs provide significantly greater comprehensiveness of wraparound services


For wraparound services…

• TCs offer more comprehensive services overall than public & private programs

• TCs are more likely to offer specific services such as:– Family & childcare services– Employment & financial services– Legal services

• TCs are less likely to offer integrated care for co-occurring mental health & substance abuse conditions


Are there differences between TCs and other programs in

overall service comprehensiveness?


Service Comprehensiveness

7.547.99

8.75

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Private Public TC

• Service comprehensiveness as sum of core and wraparound services

• TCs scored significantly higher on overall service comprehensiveness, relative to publicly and privately funded non-TC programs


Summary• There were not differences between the 3

types of centers in the number of core services offered, but some differences in availability of specific services:– TCs higher on individual therapy, drug testing, and 12-

step groups, but lower on pharmacotherapy and aftercare

• TCs offer significantly more wraparound services, which results in higher overall score for service comprehensiveness

• There’s room for improvement across the types of centers– The average program offered about 8 out of the 15

services


Meeting the Treatment Needs of Women in Mixed Gender & Women

Only Settings


Background

• Male dominated field– Women represent a small albeit increasing portion of

consumers in substance abuse treatment.

• Growing interest in women’s treatment needs.– Research indicates that women and men’s substance abuse and

substance abuse treatment needs differ (Grella & Joshi 1999; Rosenbaum 1981).

– In particular, women face a number of barriers to treatment entry, retention, and completion (Copeland 1995; Grant 1995; Weisner 1992).

• Traditional programs for men are modifying to meet the needs of women.– For example, modified therapeutic communities for women

incorporate specialized treatment services for women (NIDA 2002).


Background, cont.

• Options for women consumers include treatment in :

– Mixed gender settingsMixed gender settings Women and men received the same treatment.

– Women only programsWomen only programs Women receive separate—but the same—

treatment from men.

– Enhanced women only programsEnhanced women only programs Women received separate—and different—

treatment from men, which specifically targets women’s needs.

– Child care, prenatal care, women-focused topics/ therapies, mental health and comprehensive wrap-around services.


Prior Research

• Effectiveness of women only programs and enhanced women’s programs is consistently reported in the literature.

– Women have superior treatment outcomes in enhanced women-only programs (Sun 2006; Ashley, Marsden, & Brady 2003; Bride 2001; Orwin & Bernichon 2001).

– Evaluations of therapeutic communities for women, in particular those with a child live-in option, evidence a number of positive effects (Coletti et al. 1995; Hughes et al. 1995; Stevens & Gilder

1994).


Research Questions1. How prevalent are women only programs in the

U.S., and how are these programs distributed by sector (TC, public, private)?

2. To what extent do women only TCs incorporate female-sensitive enhancements?

3. How have modifications for women changed the essential elements of the traditional TC model?

4. On average, do enhancements such as child care options improve treatment completion for women?


Data & Variables of Interest• NTCS (TC, public, & private samples—2002-2004)

– Face-to-face interviews with program administrators/clinical directors in the U.S.

• Key variables:– Proportion of female clients

Categorized: male only, mixed gender, & women only– Availability of female-sensitive enhancements

Extent of provisions for comprehensive services (self report, 0-5 scale),

Availability of child care (y/n), integrated care (y/n), special treatment tracks for trauma survivors (y/n)

Emphasis on specific therapeutic orientations (self report, 0-5 scale),

– Extent to which essential TC elements characterize program (self report, 0-5 scale) (adapted from Melnick & De Leon 1999)

– Proportion clients completing prescribed treatment program


How prevalent are women only programs in the U.S.,

and how are these programs distributed by sector (TC,

public, private)?


Gender Composition by Sector

20.8%

6.3%1.7%

60.7%

83.2%

96.5%

18.5%

10.5%

1.7%0%

20%

40%

60%

80%

100%

Male only Mixed Gender Women only

TC (n=380) Public (n=363) Private (n=403)

• Compared to public and private centers, TCs are significantly more likely to provide single sex treatment—both male only and women only programs (p < .001).

• In the majority of centers, regardless of sector, treatment is provided in mixed gender settings.


Women in Treatment• Women represent, on average, 38% of clients.

• In mixed gender settings, women make up 35.7% of clients, on average. – TC—33.2% – Public—35.0% – Private—37.7%

Private centers differ significantly from Public (p < .05) and TCs (p < .001).

• Half of the mixed gender programs provide special treatment tracks for women.– TC—53.0% – Public—58.6%– Private—35.6%

Private centers differ significantly from Public and TCs (p < .001).


To what extent do women only TCs incorporate female-sensitive enhancements?


Comprehensive Services(Self-report, 0 -5 scale)

Mixed Gender TCs

(n=230)

Women Only TCs

(n=70)Sig.

Medical Problems 4.32 4.47

Dental Problems 3.81 4.27p < .05

Employment Problems 3.76 3.83

Legal Problems 3.89 4.17

Family/Social Problems 4.53 4.56

Psychological/Emotional Problems 4.51 4.67

Financial Problems 3.35 4.00p < .01


Female-Sensitive Enhancements

Integrated Care, Trauma Track, Child Care Programs

55.7%50.0%

24.0%

39.0%

19.0%

61.0%

0%

10%

20%

30%

40%

50%

60%

70%

IntegratedCare

TraumaTrack*

Child Care**

Mixed Gender TCs Women Only TCs *p < .05**p < .001


Therapeutic Style(Self-report, 0 – 5 scale)

MixedGender TCs

(n=230)

WomenOnly TCs

(n=70)Sig.

Supportive Group Therapy 4.75 4.83

Confrontational Group Therapy 3.15 2.77p < .01

Family Therapy 3.41 3.44

Supportive Individual Therapy 4.62 4.63

Individual Psychotherapy 2.98 2.91

Social Learning 4.41 4.66p < .10


To what extent have modifications for women

changed the essential elements of the traditional TC model?


TC Essential Elements(Self Report, 0 – 5 scale)

Mixed Gender TCs

(n=230)

Women Only TCs

(n=70)Sig.

TC Perspective4.65 4.77

Hierarchy3.68 4.15 p < .05

Clients as Therapists4.27 4.45

Work as Therapy3.63 4.16 p < .01

Aspects of Program4.27 4.64 p < .01

Disciplinary Actions 4.55 4.87 p < .05


On average, do enhancements such as child care options

improve treatment completion for women?


Treatment Completion: Effect of Child Care Program

• In the average TC (male and female), a little more than 63% of clients complete their prescribed treatment program.

• Women only programs evidence lower percentages of completion than mixed gender TCs.

• The availability of child care has a pronounced effect on treatment completion for women only programs.

53.2%

61.4%

0%

10%

20%

30%

40%

50%

60%

70%

No ChildCare

Child Care

N.S.; p=.164


Summary of Results• Women only programs are significantly more prevalent

among TCs compared to public and private centers (p < .001).

• Women only TCs as compared to mixed gender TCs are more likely to offer female-sensitive enhancements.– Provisions for dental (p < .01) & financial problems (p < .01)– Trauma Tracks (p < .05) & Child Care (p < .001)

• Women only TCs are less confrontational (p < .01) and place more emphasis on social learning approaches (p < .10).

• Essential TC elements are not compromised by modifications to women only TCs.

– Women only TCs are “more TC” than mixed gender programs.

• Availability of child care programs in women only TCs has a substantial effect on treatment completion.


For More Information about the NTCS:

www.uga.edu/ntcs

Downloadable reports, presentations, abstracts of

publications, etc.

the university of georgia challenges for the modern tc: balancing tradition with the demands of...

Documents

private funding

nonprofit programs

funding sources

methadone programs

spectrum of programs

public centers80

treatment modelinterviews

public fundingaverage