The University of Georgia Challenges for the Modern TC: Balancing Tradition with the Demands of Today’s Health Care System J. Aaron Johnson Hannah K. Knudsen Meredith H. Dye This research is supported by NIDA Research Grants R01DA13110, R01DA14482, & R01DA14976

The University of Georgia 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 University of Georgia The National Treatment Center Study: An Overview

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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

The University of Georgia Types of Programs NOT in the NTCS Programs based in correctional settings VA programs Halfway houses & transitional housing DUI services Counselors in private practice

The University of Georgia 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

The University of Georgia 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 = Public, 1084 Private, 1043 TC counselors

The University of Georgia Therapeutic Communities: Organizational Characteristics

The University of Georgia 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

The University of Georgia Distribution of TC Age

The University of Georgia Organizational Size in FTEs

The University of Georgia 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

The University of Georgia Client Characteristics: Primary Diagnosis Administrators were asked about the distribution of their TC’s caseload by primary diagnosis The average for cocaine & alcohol were similar

The University of Georgia Client Characteristics: Demographic Characteristics Administrators were asked to describe the demographic characteristics of the TC’s caseload

The University of Georgia Staffing the Modern TC

The University of Georgia The Addiction Workforce: Characteristics of Counselors

The University of Georgia 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.?

The University of Georgia Descriptives PublicPrivateTC % Female64.0 a Age % White64.2 a,b 82.2 c 56.0 % Af. Am.22.5 a,b 10.2 c 29.4 % Hispanic7.9 a,b 3.4 c 8.8 % Recovery50.8 b 52.9 c 57.0 a = Public/Private sig. different; b = Public/ TC sig. different; c = Private/ TC sig. different

The University of Georgia Counselor Salary TC counselors have sig. lower salaries than both public and private programs

The University of Georgia Counselor Credentials, Training and Experience

The University of Georgia Counselor Education % of counselors w/ college degrees almost = across all three types of programs. % MA or higher counselors sig. higher in public and private programs

The University of Georgia Counselor Certification/Licensure A significantly lower percentage of TC counselors have obtained certification and/or licensure

The University of Georgia Hours of Training: Within and Outside Program 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)

The University of Georgia Counselor Tenure at Center/ Tenure in Field (In Years) 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)

The University of Georgia 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

The University of Georgia Comparing Voluntary Turnover Public centers and TCs have significantly higher turnover than private centers (p<.001)

The University of Georgia What do we know about the differences between these types of programs that might explain differences in counselor turnover?

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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)

The University of Georgia 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

The University of Georgia 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.

The University of Georgia Service Comprehensiveness in Addiction Treatment Hannah K. Knudsen, Ph.D.

The University of Georgia 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

The University of Georgia 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

The University of Georgia 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?

The University of Georgia 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

The University of Georgia Are there differences between TCs and other programs in the availability of core addiction services?

The University of Georgia Core Addiction Services Assessment Behavioral therapy and counseling (individual and group) Substance use monitoring Pharmacotherapy Self-help/Peer support groups Continuing care

The University of Georgia 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

The University of Georgia Strong Emphasis on Individual and Group Therapy TCs are significantly more likely to place a strong emphasis on individual therapy than public & private programs No differences for group therapy

The University of Georgia Substance Use Monitoring: Drug Testing During Treatment 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

The University of Georgia Pharmacotherapy 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)

The University of Georgia Self-Help/Peer Support Groups 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

The University of Georgia Continuing Care/Aftercare 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)

The University of Georgia Comprehensiveness of Core Addiction Services Comprehensiveness of core addiction services as number of services offered No significant differences by center type

The University of Georgia 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

The University of Georgia Are there differences between TCs and other programs in the availability of wraparound services?

The University of Georgia Wraparound Services Medical services Mental health services Family services Childcare Transportation assistance Legal services Employment-related services Financial services

The University of Georgia Medical & Mental Health Services 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

The University of Georgia Family-Related & Childcare Services 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)

The University of Georgia Transportation and Legal Services Compared to public and private centers, TCs are more likely to offer services that provide assistance with: –Transportation –Legal problems

The University of Georgia Employment and Financial Services Compared to public and private centers, TCs are more likely to offer services that provide assistance with: –Employment needs –Financial problems

The University of Georgia Comprehensiveness of Wraparound Services Comprehensiveness of wraparound services as number of services offered TCs provide significantly greater comprehensiveness of wraparound services

The University of Georgia 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

The University of Georgia Are there differences between TCs and other programs in overall service comprehensiveness?

The University of Georgia Service Comprehensiveness 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

The University of Georgia 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

The University of Georgia Meeting the Treatment Needs of Women in Mixed Gender & Women Only Settings

The University of Georgia 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).

The University of Georgia Background, cont. Options for women consumers include treatment in : –Mixed gender settings  Women and men received the same treatment. –Women only programs  Women receive separate—but the same—treatment from men. –Enhanced 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.

The University of Georgia 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).

The University of Georgia Research Questions 1.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?

The University of Georgia Data & Variables of Interest NTCS (TC, public, & private samples— ) –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

The University of Georgia How prevalent are women only programs in the U.S., and how are these programs distributed by sector (TC, public, private)?

The University of Georgia Gender Composition by Sector 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.

The University of Georgia 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).

The University of Georgia To what extent do women only TCs incorporate female-sensitive enhancements?

The University of Georgia Comprehensive Services (Self-report, 0 -5 scale) Mixed Gender TCs (n=230) Women Only TCs (n=70) Sig. Medical Problems Dental Problems p <.05 Employment Problems Legal Problems Family/Social Problems Psychological/Emotional Problems Financial Problems p <.01

The University of Georgia Female-Sensitive Enhancements Integrated Care, Trauma Track, Child Care Programs *p <.05 **p <.001

The University of Georgia Therapeutic Style (Self-report, 0 – 5 scale) Mixed Gender TCs (n=230) Women Only TCs (n=70) Sig. Supportive Group Therapy Confrontational Group Therapy p <.01 Family Therapy Supportive Individual Therapy Individual Psychotherapy Social Learning p <.10

The University of Georgia To what extent have modifications for women changed the essential elements of the traditional TC model?

The University of Georgia TC Essential Elements (Self Report, 0 – 5 scale) Mixed Gender TCs (n=230) Women Only TCs (n=70) Sig. TC Perspective Hierarchy p <.05 Clients as Therapists Work as Therapy p <.01 Aspects of Program p <.01 Disciplinary Actions p <.05

The University of Georgia On average, do enhancements such as child care options improve treatment completion for women?

The University of Georgia 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. N.S.; p=.164

The University of Georgia 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.

The University of Georgia For More Information about the NTCS: Downloadable reports, presentations, abstracts of publications, etc.