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Abstract: The health services field is increasingly concerned about burnout and turnover among service providers. Substance abuse professionals are particularly susceptible to burnout since factors such as large caseloads, limited resources, low pay, and bureaucratic work environments contribute to burnout. In addition, substance abuse professionals work with a challenging client population of addicts and referrals from the criminal justice system which can leave them feeling frustrated, depressed, and helpless in assisting clients. Examining work environment factors that are amenable to change may make a difference in curbing burnout (and ultimately deterring turnover) among substance abuse counselors. Clinical supervision is one such factor, as it is the primary mechanism for on-the-job training and counselor development. Further, negative experiences in clinical supervision can contribute to burnout and ultimately turnover. As such, the authors propose that positive experiences with one’s clinical supervisor may reduce counselor burnout whereas negative experiences may actually exacerbate burnout. And consistent with previous research, burnout should predict counselor turnover intentions. This poster describes the outcomes of a CTN platform study that surveyed 462 counselors employed at fifteen CTPs (community treatment programs) in the Clinical Trials Network. Two dimensions of burnout were examined: depersonalization and emotional exhaustion. The variables of role overload, job satisfaction, and pay satisfaction were used as control variables in all of the multiple regression analyses. The results indicate that both positive and negative clinical supervisory experiences are associated with turnover intentions. Likewise, counselor burnout was associated with turnover intentions. Further, both depersonalization and emotional exhaustion were partial mediators of the relationship between positive and negative clinical supervisory experiences and turnover intentions. This study indicates that high quality clinical supervision may be important in reducing burnout and subsequent counselor intentions to turnover. The practical suggestions include in-house and education-based training on effective clinical supervision and performance management systems that hold clinical supervisors accountable for their behavior toward counselors.

Abstract:

Teleconferencing Supervision is a method for training community-based substance abuse clinicians in Motivational Interviewing (MI). In this CTN platform study, 13 clinicians recruited from 3 community treatment programs in the Long Island Node of the Clinical Trials Network attended a 2-day workshop and then received live supervision via telephone during 5 counseling sessions conducted at their community treatment facilities. Clinicians were assessed for skill level at post-workshop, at post-training, and 3 months later; learning was assessed using the MI Treatment Integrity instrument. All summary scores and therapist behavior frequency counts improved by post-training or by the 3 month follow-up, although some gains were not statistically significant.

This study suggests that Teleconferencing Supervision may help facilitate the proficient use of MI community clinicians following workshop instruction. By enabling both clinicians and supervisors to participate from their respective home bases, it is hoped that the TCS model will be able to project training to a broader range of community treatment programs.

Abstract:

Motivational interviewing (MI) is an evidence-based practice shown to be effective when working with people in treatment for substance use disorders. However, MI is a complex treatment modality optimized by training with feedback. Feedback, assessment, and monitoring of treatment fidelity require measurement, which is typically done using audiotaped sessions. The gold standard for such measurement of MI skill has been an audiotaped interview, scored by a rate with a detailed structured instrument such as the Motivational Interviewing Treatment Integrity 2.0 (MITI 20.0) Coding System. The Helpful Responses Questionnaire (HRQ) is a pen-and-paper test of empathy (a foundational MI skill) that does not require an audiotaped session.

A randomized trial of three different regimens for training counselors in MI (live supervision using teleconferencing, tape-based supervision, and workshop only) offered the opportunity to evaluate the performance of the HRQ as a measure of MI ability, compared to the several MITI 2.0 global scores and subscales. Participants were counselors (N=97) from 26 community-based substance use treatment programs affiliated with the Long Island and New York Nodes of the NIDA Clinical Trials Network, whose MI proficiency was measured at 4 time points: baseline (before an initial 2-day MI workshop), post-workshop, 8 weeks post-workshop (i.e., post-supervision), and 20 weeks post-workshop with both MITI 2.0 and HRQ

HRQ total scores correlated significantly with the Reflection to Question Ratio from the MITI 2.0 at post-workshop, week 8, and week 20, and with the Spirit and Empathy global scores at week 20. Correlations of HRQ with other MITI 2.0 subscales and time points after workshop were small and not significant. As predicted, HRQ scores different between training conditions, with counselors assigned to live supervision achieving better HRQ scores than those in Workshop only.

Conclusions: The HRQ is a modestly accurate measure, mainly of the Reflection to Question ratio, considered a core marker of MI skill. It is sensitive to training effects and may help identify counselors needing more intensive supervision. Given its ease of administration and scoring, HRQ may be a useful marker of MI skill during training efforts.

Abstract:

Learning motivational interviewing (MI) is an ongoing process, involving much more than attendance at a single workshop. Once proficiency is achieved, therapists benefit from ongoing coaching with individual feedback based on observed practice to ensure continued fidelity. The aim of this study was to assess outcomes of the unique training and supervision model employed in a recent trial of MI. The intervention tested in the six-site National Drug Abuse Treatment Clinical Trials Network protocol CTN-0047 trial was a 30-minute MI-based brief intervention delivered in the emergency department followed by two telephone booster calls delivered from a centralized call center. Thirty-one counselors and 3 booster counselors were trained in the intervention using a 2-stage process: local training in the MI process of engagement followed one month later by a 2-day training in MI. We employed a two-level model in which the formal coding was separated from the clinical supervision. One audio file per interventionist per week was coded using the MITI 3.1.1 coding system. This written feedback was available to clinical supervisors, who reviewed coding results during telephone supervision sessions.

Eleven percent of sessions were coded on an ongoing basis during the trial, with a total of 380 initial sessions (90%) and 83 booster sessions (20%) coded upon completion of the trial. Mean global scores for initial sessions ranged from 4.25 to 4.67, and for the booster sessions from 4.64 to 4.86, well above the proficiency benchmark of 4.0. Inter-rater reliability assessed on a random sample of 124 tapes was excellent, with ICCs averaging 0.81 for global scores and 0.93 for behavior counts. On a therapist level, MITI scores tended to improve over time, demonstrating the strategies employed helped with adherence and continued learning in MI.

Conclusions: A comprehensive strategy for successfully learning and maintaining skills in MI emerged from the CTN-0047 study, which employed a rigorous and novel plan for ensuring therapists adhered to the style of MI.

Related protocols: CTN-0047

Abstract:

The objective of this study was to investigate the relation between self-report and objective assessment of Motivational Interviewing (MI) skills following training and supervision. After an MI workshop, 96 clinicians from 26 community programs participating in NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) were randomized to supervision (tele-conferencing or tape-based) or workshop-only. At four time points, trainees completed a self-report of MI skill, using items from the MI Understanding Questionnaire (MIU), and were objectively assessed by raters using the Motivational Interviewing Treatment Integrity (MITI) system. Correlations were calculated between MIU and MITI scores. A generalized linear mixed model was tested on MIU scores, with MITI scores, supervision condition and time as independent variables. MIU scores increased from pre-workshop (mean=4.74, SD=1.79) to post-workshop (mean=6.31, SD=1.03). With supervision, scores continued to increase, from post-workshop to week 8 (mean=7.07, SD=0.91, t=5.60, p<.0001) and from week 8 to week 20 (mean=7.28, SD=0.94, t=2.43, p=.02). However, MIU scores did not significantly correlate with MITI scores, with or without supervision. Self-reported ability increased with supervision, but self-report was not an indicator of objectively measured skill.

Conclusions: This study suggests that training does not increase correspondence between self-report and objective assessment, so community treatment programs should not rely on clinician self-report to assess the need for ongoing training and supervision and it may be necessary to train clinicians to accurately assess their own skill. This has important implications for community treatment, where time and resources may constrain the amount of MI training and supervision provided. Nevertheless, using self-report as a proxy for ability may have a serious negative impact on public health, as proficiency in MI is tied to client improvement, and clinician-perceived understanding of MI does not actually equate to proficiency in MI.

Abstract:

This study examined the relationships between treatment fidelity and treatment outcomes in a community-based trial of 12-Step Facilitation (TSF) intervention. In a prior multi-site randomized clinical trial, National Drug Abuse Treatment Clinical Trials Network protocol CTN-0031, 234 participants in 10 outpatient drug treatment clinics were assigned to receive the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention. This secondary analysis reviewed and coded all STAGE-12 sessions for fidelity to the protocol, using the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF-ACES). Linear mixed-effects models tested the relationship between three fidelity measures (adherence, competence, empathy) and six treatment outcomes (number of days of drug use and five Addiction Severity Index (ASI) composite scores) measured at 3 months post-baseline. Adherence, competence, and empathy were robustly associated with improved employment status at follow up. Empathy was inversely associated with drug use, as was competence in a non-significant trend (p=.06). Testing individual ASI drug composite score items suggested that greater competence was associated with fewer days of drug use and, at the same time, with an increased sense of being trouble or bothered by drug use.

Conclusions: Greater competence and empathy in the delivery of a TSF intervention were associated with better drug use and employment outcomes, while adherence was associated with employment outcomes only. Higher therapist competence was associated with lower self-report drug use, and also associated with greater self-report concern about drug use. The nature of TSF intervention may promote high levels of concern about drug use even when actual use is low. This study is suggestive, but not conclusive, that higher fidelity intervention is associated with improved treatment outcome.

Related protocols: CTN-0031, CTN-0031-A-3

Abstract:

New York State required substance use disorder (SUD) treatment programs to be 100% tobacco-free in 2008. The current study, part of the CTN platform study Managing Effective Relationships in Treatment Services (MERITS II), examined counselor (N=364) and clinical supervisor (N=98) perceptions of how extensively the tobacco-free regulation was implemented in their treatment programs, perceived accountability for implementing the regulation, and use of OASAS-provided resources to aid implementation one year after the regulation went into effect. Results showed that compared to counselors, supervisors perceive greater implementation extensiveness and report using more resources, yet they perceive lower accountability. In addition, whereas perceived accountability is significantly and positively associated with implementation extensiveness perceptions for counselors, the relationship is negative for supervisors. The association between use of resources and implementation extensiveness perceptions is significant and positive for both counselors and supervisors.

Conclusions: Implementation experiences differ between counselors and clinical supervisors, suggesting the importance of tailoring interventions to promote tobacco-free policies in SUD treatment programs. This study adds to the sparse literature on implementation research in SUD treatment, as well as providing a better understanding of the implementation of the OASAS tobacco-free regulation.

Abstract:

Therapist characteristics may be associated with variation in consistency, quality and effectiveness of treatment delivery. This ancillary investigation of National Drug Abuse Treatment Clinical Trials Network protocol CTN-0031 (Stimulant Abuser Groups to Engage in 12-Step (STAGE-12)) examined associations between treatment fidelity and therapist education, experience, treatment orientation, and perceived skills. Raters scored audio-recorded TSF sessions (n=966; 97% of TSF sessions) from 32 community-based, trained therapists for adherence, competence, empathy, and global session performance. Therapists with graduate degrees had significantly higher adherence and global performance fidelity ratings. Therapists reporting more positive attitudes toward 12-Step groups had lower adherence ratings. Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis. Fidelity was higher for therapists reporting self-efficacy in basic counseling skills and lower for self-efficacy in addiction-specific counseling skills. Fidelity was also superior in group relative to individual TSF sessions.

Conclusions: Results from this study have implications for therapist selection, training, and supervision in community-based, effectiveness trials and community implementation of evidence-based treatments. To obtain high fidelity and improve outcomes, it may be preferable to choose masters level therapists who are open to learning new treatments and have good, general counseling skills.

Related protocols: CTN-0031, CTN-0031-A-3

Abstract:

When mental health counselors have inadequate training in substance use disorders (SUDs), effective clinical supervision (ECS) may advance their professional development. The purpose of this study was to investigate whether ECS is related to the job performance of SUD counselors. Data were obtained in person via paper-and-pencil surveys from 392 matched SUD counselor-supervisor dyads working in 27 SUD treatment organizations across the United States, all participating in the National Drug Abuse Treatment Clinical Trials Network platform study, “Managing Effective Relationships in Treatment Services” (MERITS I). Counselors rated ECS on five multi-item scales (sponsoring counselors’ careers, providing challenging assignments, role modeling, accepting/confirming counselors’ competence, and overall supervisor task proficiency). Clinical supervisors rated counselor job performance on two multi-item scales (task performance and performance within the supervisory relationship). Using mixed-effects models, the authors found that most aspects of ECS are related to SUD counselor job performance. Thus, ECS may indeed enhance counselor performance on tasks and within the supervisory relationship, which may offset the limited formal SUD training.

Abstract:

Counselor emotional exhaustion has negative implications for treatment organizations as well as the health of counselors. Quality clinical supervision is protective against emotional exhaustion, but research on the mediating mechanisms between supervision and exhaustion is limited. Drawing upon data from 934 counselors affiliated with treatment programs in the National Drug Abuse Treatment Clinical Trials Network (CTN), this study examined commitment to the treatment organization and commitment to the counseling occupation as potential mediators of the relationship between quality clinical supervision and emotional exhaustion. The final ordinary least squares (OLS) regression model, which accounted for the nesting of counselors within treatment organizations, indicated that these two types of commitment were plausible mediators of the association between clinical supervision and exhaustion. Higher quality clinical supervision was strongly correlated with commitment to the treatment organization as well as commitment to the occupation of SUD counseling.

These findings suggest that quality clinical supervision has the potential to yield important benefits for counselor well-being by strengthening ties to both their employing organization as well as the larger treatment field, but longitudinal research is needed to establish these causal relationships.

Abstract:

The main goals of the current study were to investigate whether there are linear or curvilinear relationships between substance use disorder counselors’ job performance and actual turnover after 1 year utilizing four indicators of job performance and three turnover statuses (voluntary, involuntary, and no turnover as the reference group). Analyzing longitudinal data collected in 2007 and 2008 as part of the Managing Effective Relationships in Treatment Services (MERITS I) project, a CTN platform study, results indicated that overall, counselors with lower job performance are more likely to turn over voluntarily and involuntarily than not to turn over. Further, one of the job performance measures shows a significant curvilinear effect.

Conclusions: The negative consequences often assumed to be “caused” by counselor turnover may be overstated because those who leave both voluntarily and involuntarily demonstrate generally lower performance than those who remain employed at their treatment program. These findings underscore the importance in investing in recruitment, selection, and training in SUD treatment in an effort to reduce the costs of turnover and increase the likelihood of successful hires that will perform well and remain employed at the treatment organization.

Abstract:

Based on mentoring theory, social exchange theory, and theories of stress and coping, this study of data from the 2008 Managing Effective Relationships in Treatment Services project (MERITS I, a National Drug Abuse Treatment Clinical Trials Network (CTN) platform study) examined antecedents and consequences of the provision of mentoring support by clinical supervisors. Of particular interest is how the provision of mentoring support is further linked to counselor’s experience of work-to-nonwork conflict. Survey data were collected in person in 2008 from 418 matched clinical supervisor-counselor dyads who worked in substance use disorder treatment programs across the U.S. Path analysis showed that clinical supervisors’ evaluation of relational costs, relational benefits, and overall relationship quality with a particular counselor was related to the counselor’s perception of the amount of mentoring support provided. In turn, perceived mentoring support was negatively related to both strain-based and time-based work-to-nonwork conflict among counselors.

Conclusions: These findings suggest that counselors and clinical supervisors should be made aware of and encouraged to create positive social exchanges, foster quality relationships, and promote mentoring support to help address and reduce counselors’ work-to-nonwork conflict, likely increase well-being, and possibly promote positive outcomes for organizations, such as reduced turnover and improved performance.

Abstract:

Effective training and ongoing coaching in psychosocial treatment modalities is critical to maintaining fidelity in both research and practice. Maintaining fidelity may be particularly challenging in emergency department settings due to the fast pace and competing urgent and emergent priorities. This presentation describes intervention training, certification, supervision and fidelity monitoring procedures used in the NIDA CTN six-site “Screening Motivational Assessment and Referral to Treatment in Emergency Departments (SMART-ED)” study. Interventionists received a 2-day training in basic motivational interviewing skills, followed 1 month later by a 2-day training in the specific intervention used in this trial. Practice sessions with consenting ED patients were reviewed by expert raters, using the Motivational Interviewing Treatment Integrity scale (MITI, v.3.1.1), to determine if interventionists had reached benchmark scores and were therefore certifiable. Clinical supervision of interventionists was conducted independently of fidelity monitoring; centralized fidelity monitors reviewed 12% (n=96) of interventionists’ sessions and reported MITI scores to clinical supervisors to offer objective feedback regarding their supervisee’s performance. Clinical supervisors conducted bi-weekly phone supervision, discussing MI fidelity and clinical issues. Following completion of the trial, 20% of the interventionist sessions (n=161), of which 30% (n=55) were coded by two independent raters to assess inter-rater reliability, were randomly selected and coded for overall trial fidelity. Participating interventionists were 21 females and 12 males with little experience in addiction counseling (M=1.58 +/- 2.5 years). Fidelity monitoring during the trial successfully prevented drift and identified only one interventionist in need of remedial supervision. Bi-weekly coaching continued throughout the trial and interventionists found these sessions useful in maintaining their skills. Results from fidelity monitoring indicate above average performance on MITI scores.

Conclusions: The two-stage interventionist training, bi-weekly supervision, and ongoing monitoring produced excellent results and prevented drift. This model may bestow an advantage for learning and implementing brief interventions based on an MI approach.

Related protocols: CTN-0047

Abstract:

Little is empirically known about clinical supervision in addiction treatment. This study describes multiple domains of clinical supervision in addiction treatment from the perspectives of clinical supervisors and their counselors. Survey data were obtained from 484 matched clinical supervisor-counselor dyads who participated in the Managing Effective Relationships in Treatment Services (MERITS I) project (a NIDA-funded National Drug Abuse Treatment Clinical Trials Network (CTN) platform study). Four main conclusions can be drawn from the results of this study. First, supervisors have wide-ranging experience and training in supervision. Second, supervisors are generally viewed as effective in their job performance by counselors. Third, supervisors report significantly more time interacting with their counselors than counselors report spending with their supervisors. Fourth, a wide variety of methods are used to interact with and deliver feedback to counselors, although supervisors report greater use of these diverse methods than do their counselors.

Conclusions: While clinical supervision in addiction treatment programs seems to be effective, there is still room for improvement. Supervisors should devote more energy to their interactions with counselors, particularly because these interactions help foster professional growth and competence.

Abstract:

Training through traditional workshops is relatively ineffective for changing counseling practices. Teleconferencing supervision (TCS) was developed to provide remote, live supervision for training motivational interviewing. In this CTN platform study, counselors from 26 substance abuse community treatment programs affiliated with the Long Island and New York Nodes (now the Greater New York Node) of the National Drug Abuse Treatment Clinical Trials Network (CTN) completed a 2-day MI workshop and were randomized to live supervision via teleconferencing (TCS; n=32), standard tape-based supervision (tape; n=32), or workshop alone (workshop; n=33). Supervision conditions received 5 weekly supervision sessions at their sites using actors as standard patients. Sessions with clients were rated for MI skill with the Motivational Interviewing Treatment Integrity (MITI) Coding System pre-workshop and 1, 8, and 20 weeks post-workshop. Results found that those receiving TCS scored better than the workshop group on the MITI for spirit and empathy. TCS was also superior to workshop in reducing MI non-adherence and was superior to workshop and tape in increasing reflection to question ratio. Tape was superior to TCS in increasing complex reflections. The percentage of counselors meeting proficiency differed significantly between training conditions for the most stringent threshold.

Conclusions: TCS shows promise for promoting new counseling behaviors following participation in workshop training. However, further work is needed to improve supervision methods to bring more clinicians to high levels of proficiency and facilitate dissemination of evidence-based practices. A longer duration of supervision, involving a combination of techniques embodied in both TCS and tape may bring a greater proportion of community-based counselors to high levels of proficiency, but more attention is also needed to modify methods to minimize costs and time burden, so that supervision can be brought to scale and sustained broadly across the treatment system.