Symposium CLIENT –PROVIDER RELATIONSHIP AS AN ACTIVE INGREDIENT IN DELIVERY OF SOCIAL SERVICES Organizer: Jeanne C. Marsh, PhD, MSW University of Chicago School of Social Service Administration Society for Social Work and Research Washington, DC January 11-15, 2012

BACKGROUND: Client-provider relationship Historic significance in social work theory and practice (H.H. Perlman, Relationship: Heart of Helping People) Emerging services research shows capacity of client-provider relationship to function as powerful determinant of change across health and social service delivery systems.

Client-provider relationship Actively studied in the psychotherapy and counseling research under rubric of therapeutic alliance Social work research has focused more on validating the effectiveness and efficiency of treatments or technical interventions than on understanding client-provider relationship as active ingredient of change Overall research beginning to indicate specific interventions account for 5-15% of outcome variance while factors related to client-provider outcome account for more

Why study client-provider relationship as active ingredient? To understanding factors facilitating implementation of evidence-based practices To looking beyond psychotherapy literature to understand functioning of client-provider relationship in delivery of social services in mental health, substance abuse and child welfare service

Services research conceptual framework Client-provider relationship Intervention technology

PURPOSE 1. Bring together four different analytic strategies across 3 service systems of mental health, substance abuse and child welfare: 1.Systematic review of association of client-provider relationship to outcome in mental health, substance abuse and child welfare (Angel, Marsh, Andrews & Curry) 2.Quantitative analysis of proportion of outcome variance accounted for in substance abuse treatment (Shin, Marsh, Cao & Andrews) 3.Qualitative analysis of role of relationship in process of recovery in mental health (Longhofer, Kubek & Floersch) 4. Analysis of construct validity of more rigorous measurement strategies of relationship in mental health (Mahoney & Angel)

PURPOSE 2. Review what learned in last 15 years about association of client-provider relationship to key outcomes and: 1.Define core constructs and variables; 2.Describe associations and possible causal relations among variables; 3.Identify possible mediating/moderating mechanisms; 4.Highlight gaps in knowledge that point to promising directions for future research and practice.

QUESTIONS TO BE ADDRESSED What is the association of client-provider relationship to outcome across 3 service systems? What are possible moderating and mediating factors? What are conceptual and measurement considerations in research on client-provider relation? What are implications of findings for enhancing research and practice on the provision of mental health, child welfare and substance abuse treatment services?

CLIENT-PROVIDER RELATIONSHIP AS AN ACTIVE INGREDIENT IN COMPREHENSIVE SUBSTANCE ABUSE TREATMENT Hee-Choon Shin, PhD, Jeanne C. Marsh, PhD, Christina Andrews, PhD, Ashley Curry, PhD University of Chicago School of Social Service Administration Society for Social Work and Research Washington, DC January 11-15, 2012

BACKGROUND Services research increasingly documenting the effectiveness of comprehensive service models Comprehensive service models focus on the role of access services (transportation and child care), health and social services matched to client need, client-provider relationship ALONG WITH intervention technology such as substance abuse counseling

COMPREHENSIVE SERVICES RESEARCH MODEL Study examines specific ingredients of comprehensive services–factors affecting outcome: 1) Access services (transportation child care) 2) Matched services (clients receive specific services they say they need) 3) Client-provider relationship 4) Substance abuse INTERVENTION (counseling,12-step, pharmacotherapy)

Conceptual framework Client-provider relatIonship Targeted or matched services Access services

WHAT WE KNOW Intervention research has focused on determining the efficacy and effectiveness of specific treatment technologies Services research, BROADER, has been concerned with specific ingredients related to and supportive of implementation of specific technologies in context of social service delivery systems. Each of service ingredients of access, matched services, intervention technology (substance abuse treatment), client-provider relationship contribute to outcome.

WHAT WE DO NOT KNOW Do not know extent to which specific ingredients affect treatment outcomes

PURPOSE Focus on service ingredient of client- provider relationship Examine the relation of client-provider relationship to outcomes in service duration and reduced post-treatment substance use Compare the amount of outcome variance accounted for by client-provider relationship versus substance abuse counseling and other factors

DATA SET AND ANALYTIC SAMPLE Data collected for the National Treatment Improvement Evaluation Study (NTIES), a prospective, cohort study of U.S. substance abuse treatment programs collected between Analytic sample 59 service delivery units and 3,027 programs and their clients.

QUESTION #1: WHAT IS ASSOCIATION OF CLIENT-PROVIDER RELATION TO OUTCOME? ANALYTIC METHODS: Structural equation modeling (SEM) used to assess structural relations and causal connections of the comprehensive service model that included access services, substance abuse counseling services, matched services, client provider relationship and outcomes of duration and 12 month post-treatment substance use. Organizational and client factors were control variables.

WHAT IS ASSOCIATION OF CLIENT- PROVIDER RELATION TO OUTCOME? RESULTS: Standardized path coefficients indicate client-provider relationship directly predicts outcomes of (1) remaining longer in treatment, and (2) reduced post-treatment substance use --and (3) indirectly predicts outcomes by increasing number of services clients receive that they say need (matched services)

WHAT IS ASSOCIATION OF CLIENT- PROVIDER RELATION TO OUTCOME?

QUESTIONS # 2: TO WHAT EXTENT DOES CLIENT PROVIDER RELATIONSHIP ACCOUNT FOR OUTCOME VARIANCE? ANALYTIC METHOD: Pseudo-R squared: Conceptually comparable to use of OLS regression to evaluate the variance accounted for in outcome by each service factor.

TO WHAT EXTENT DOES CLIENT PROVIDER RELATIONSHIP ACCOUNT FOR OUTCOME VARIANCE? Full Model with Random Effect 4.50% Independent Contribution Client-Provider Relationship 5.98% Substance Abuse Counseling 0.10% Access 0.01% Needs Ratio 5.99% Prior Drug Use 65.86% Duration5.62%

RESULTS REGARDING VARIANCE ACCOUNTED FOR IN POST-TREATMENT DRUG USE? 1.Largest variance accounted for pre- treatment drug use 2.Of service factors in comprehensive service model, matching services (5.99%) and client-provider relationship (5.98%) most important factors -- of comparable magnitude.

CONCLUSIONS Findings point to important role for client- provider relationship in (1) insuring receipt of targeted services, (2) increasing treatment duration and, ultimately, reduced post-treatment substance use Shows client-provider relationship (and matched services) more than intervention contribute to outcome variance (Are we surprised?)

CONCLUSIONS Among service ingredients analyzed client-provider relationship is a very active ingredient in substance abuse treatment Overall, service delivery factors like client provider and matched services are important predictors of outcome – accounting for more of outcome variance - - than service technology of substance abuse counseling

IMPLICATIONS We should systematically include client- provider relationship as an important element in development of service delivery models We should consider the implications of these findings in our efforts to train practitioners who are able to implement evidence-based practices