Fulfilling the Mission, Closing the Gap
Andrew Bordt - M.Ed.
Licensed Educator / Behavioral Health and Addiction Treatment
This article is the concluding piece of the three-part series addressing pain points across the behavioral health space.
Our previous publications emphasized the importance of measurement and staff investment (training & development, support that accompanies organizational policy shifts, etc.). This article focuses on enhancing quality care, reducing patient readmittance, building a differentiated program that fulfills its mission statement, and bridging the connection between measurement-based care (MBC), training, and improved clinical outcomes.
Today, we discuss what is at the heart of every mission statement in the industry: the patients.
The resumption of use rates for addiction vary depending on the substance or behavior being addressed, the type of treatment, and the individual's specific circumstances, but these are the general statistics for the most common types of addiction:
For our colleagues who work in the department of corrections, according to the Bureau of Justice Statistics (BJS), which is part of the U.S. Department of Justice, about two-thirds (67.8%) of released prisoners were rearrested within three years of release, and more than half (56.7%) were reincarcerated during that same period, and many involve substance use (BJS, 2021).
It's important to note that resumption of use rates are not an exact science and can vary depending on a range of individual and environmental factors. However, research has consistently shown that ongoing support and maintenance, such as continued therapy, peer support groups, and lifestyle changes, can significantly reduce the risk over time (SAMHSA, 2019; Kelly & Yeterian, 2021; NIDA, 2021).
Needless to say, readmittance rates of 30% or higher indicate there is a problem, and it is one the payers will notice, but even providers who are currently beating these percentages should pay attention because lives are on the line and every provider has a mission to fulfill.
Same Ingredients, Different Meals
"When two chefs are working with the same ingredients, how different will their meals be? The answer here is startlingly clear. There are often large differences among therapists who are offering the same or similar treatment over time” (Miller & Moyers, 2021).
Good intentions aside, therapy delivered badly can hurt patient outcomes. Therapy is a complex and multifaceted process that involves building a relationship of trust and collaboration between the therapist and the patient, as well as using evidence-based techniques to address the patient's needs.
According to Miller & Moyers (2012), "One of the largest determinants of client outcomes is the counselor who provides treatment... In discussions regarding the merits of evidence-based addiction treatment, prominent attention has focused on the effect of therapist variables on behavior change (Imel, Wampold, & Miller, 2008; Morgenstern & McKay, 2007). Indeed, it appears that one of the strongest determinants of clients’ outcomes in addiction treatment in particular is the counselor to whom they happen to be assigned (Luborsky, McLellan, Diguer, Woody, & Seligman, 1997; Luborsky, McLellan, Woody, O’Brien, & Auerbach, 1985; Kraus, Castonguay, Boswell, Nordberg & Hayes, 2011; McLellan, Woody, Luborsky, & Goehl, 1988; Miller, Taylor, & West, 1980; Valle, 1981)."
In addition, a meta-analysis of 30 studies (Flückiger et al., 2012) found that the therapeutic alliance, which includes dimensions of empathy and warmth, was the most consistent predictor of treatment outcomes across different types of therapy and patient populations. Furthermore, a review of 295 studies (Lambert & Barley, 2001) found that the therapeutic relationship accounted for more than 30% of the variance in treatment outcomes.
While 30% is significant, it shows us that 70% of treatment outcomes are related to other factors. But, sticking with the alliance, we must ask, how does one build it? Building an alliance is the result of concrete skills - active listening, affirmative statements, open-ended questions. It's not some amorphous froo-froo; rather, it's a set of concrete skills that can be learned, practiced, and improved upon.
A therapist who is untrained or inexperienced, lacks empathy or sensitivity, or who imposes their own values or beliefs on their patients can cause harm. In some cases, therapy can even exacerbate existing mental health issues or lead to the development of new ones. For example, a therapist who is overly confrontational or critical may cause a patient to feel attacked or ashamed, leading to feelings of anger or despair (Miller & Moyers, 2012). Additionally, a therapist who is not attentive to boundaries or ethical guidelines may exploit their patients or create a power dynamic that is harmful. Finally, a clinician who simply informs patients what recovery coping skills are, but does nothing to train the patients how to use them, sets their patients up for failure outside of treatment; they leave with renewed confidence and ideas in their head, but no actionable skills to improve their lives.
A Tale of Two Therapists: Which One Would You Choose for a Loved One in Crisis?
The therapeutic alliance is vital; it is the gateway to the therapeutic process.
"Based on over 300 studies, the positive relation of the alliance and outcome remains across assessor perspectives, alliance and outcome measures, treatment approaches, patient (intake-) characteristics, face-to-face and Internet-mediated therapies, and countries. Meaning: The alliance, which is of a mutual collaboration and partnership between therapist and client, is an important aspect of psychotherapy across various psychotherapy approaches" (Flückiger et al., 2018).
But it doesn't end there.
Enter Clinician A and Clinician B, who both score a 10 out of 10 on one of the various measures available to rate the therapeutic alliance between a therapist and their patient, but their outstanding results in this aspect of care is where the similarities stop.
The Delivery of CBT/DBT/REBT -
Clinician A, in addition to helping patients process challenging emotions and heal, delivers CBT, DBT, and/or REBT in a didactic fashion where patients leave understanding the idea of what mindfulness is, what boundaries are, what an "I" statement is, etc., and nod their heads when asked if they know how all of these things connect to long-term recovery.
Conversely, Clinician B, in addition to helping patients process challenging emotions and heal, delivers CBT, DBT, and/or REBT actively in a fashion where patients demonstrate the ability to use mindfulness techniques, set and communicate boundaries, use "I" statements in close to real-world situations like a contentious conversation, and can explain why these recovery capital skills will help them achieve long-term recovery.
These two delivery methods will produce different outcomes because only the second includes the expectation for patients to show what they know or can do, which allows Clinician B to address misconceptions, provide targeted support, and, most importantly, give patients the opportunity to build proficiency in these skills critical for recovery.
Let’s take the example of Joey, a real patient. Joey has spent most of his life in and out of jail. He’s 28 now and hasn’t had a full week of sobriety outside jail since he was 12. Joey has a wife and 2 kids. After Joey gets out of rehab, he’s extremely enthusiastic about recovery, a life that doesn’t involve regular stints in jail, and to build a better relationship with his wife and kids. Unfortunately, upon returning home, he finds that his wife was cheating on him while he was away in rehab. They get into a huge fight. His wife tells him she’s leaving him for the other man, takes the kids, and leaves. Joey’s now alone in his house, emotionally distraught, with a strong urge to use.
Would the work with Clinician A, who explained a lot about what recovery skills should look like, be most helpful for Joey in this moment? Or would the work with Clinician B, who actively practiced these skills with Joey so that he starts using them automatically without even having to think about or try to remember them be more helpful?
Group Delivery -
In groups, Clinician A delivers therapy like individual therapy, but with more people in the room; one person talks at a time, occasionally patients will chime in on each other's situations. Clinician A hopes the patients who aren't talking are paying attention the whole time, but they can't be sure.
In groups, Clinician B utilizes other group members to help each other process and practice recovery capital skill-building with one another using activities designed to meet the needs of diverse groups (background, education level, culture, etc.). Clinician B knows whether or not the patients are engaged with the topic because no one is passively listening. Also, Clinician B monitors conversations and provides help and direction when necessary; no guessing is involved.
In the first example, patients are likely to zone out, which means they aren’t progressing. It is also likely some topics or ideas will be misunderstood by some patients, but this will almost always go unnoticed. In the second example, every patient is actively engaged in the session throughout, mistakes are caught because patients are talking and doing; everyone is moving forward together.
Measurement and Outcomes -
Clinician A gets no real-time updates on how patients are doing aside from their observations and interactions, which is a small percentage of an overall week.
On the other hand, in addition to their own observations and interactions, which is a small percentage of their overall week, Clinician B gets real-time data through the outcomes tracking tool on how patients are responding, so they can make adjustments or intervene if necessary.
It is also important to note that the feedback a clinician receives on their performance from their Clinical Director, supervisor, or outside auditor can also impact patient outcomes. Feedback is a crucial component in the process of learning and improving performance. It allows individuals to understand how well they are doing and where they can improve, providing them with a clear direction for action. Additionally, feedback helps individuals to maintain motivation and engagement, as they can see the progress they are making over time. The better a therapist is at the multifaceted components of their job, the better their patients, overall and over time, will do. The problem is, many therapists don’t receive regular observations and feedback on their performance at all. At times, this is due to organizational issues with staffing or scheduling; other times, because the supervisor has not been trained or a rating system established. In fact, a study by Ellis et al, found that 93% of psychotherapy supervision is inadequate (Ellis et al., 2014;)
Experience can certainly contribute to better performance in a particular task or field, but without feedback, it can be difficult for individuals to identify areas for improvement and make necessary adjustments to their approach.
According to The Society for the Advancement of Psychotherapy, “It goes without saying that benchmarking performance is not an exact science, and thus there are an infinite number of reasons why therapists’ performances differ. In addition, the results cannot provide sufficient explanation for any particular therapist with a particular set of clients. Regardless, we believe that the results provide unwavering confidence that measuring performance, albeit with imperfections, is better than not measuring performance (SAP, 2023)”
We are all human after all, and the more information we have to help the patients, whether it be on our performance from a supervisor or from clients themselves, the better.
Returning to Clinicians A and B, keeping in mind that both scored high in the therapeutic alliance, are both equally setting their patients up for success outside of treatment?
Neuroplasticity is real, recovery is possible, and there are proven strategies to help people acquire, retain, and recall knowledge and skills that are, by measurement, better than others, especially when dealing with diverse groups of people.
While a strong therapeutic alliance is a critical first step, it is not the only step in delivering the highest quality of care. These other considerations are irrelevant without a strong alliance in place, but they are difference-makers once the alliance is established.
Using Research Science to Make a Difference
Knowledge and skill are two related but distinct concepts:
Knowledge refers to the understanding of information, facts, concepts, or principles that a person has acquired through learning or experience. Knowledge can be acquired through reading, studying, listening, observing, and reflecting.
Skill, on the other hand, refers to the ability to perform a task or activity with proficiency and expertise. Skill is acquired through practice, repetition, and experience. It requires the application of knowledge to a specific task or situation.
Simply speaking, knowledge is about having information, while skill is about being able to apply that knowledge to achieve a specific goal or perform a specific task effectively. This applies to recovery as much as it does typing on a keyboard; simply knowing what boundaries are is not enough to ensure success outside of treatment. The ability to set, communicate, and stick to boundaries are processes which require motivation, guidance, and practice.
The procedural pathway in the brain, involving the prefrontal cortex, basal ganglia, primary motor cortex, and cerebellum is responsible for the acquisition and execution of motor skills as well as cognitive processes, such as problem-solving and decision-making (Fiez & Petersen,1998; Poldrack, 2001).
Through repeated practice, the procedural pathway in the brain becomes more efficient, allowing for faster and more accurate execution of tasks. This process is known as motor learning and involves changes in the connections between neurons in the brain.
Additional recovery coping skills practice can be tremendously helpful for people recovering from addiction in several ways:
Improved Self-Awareness: Recovery coping skills practice can help individuals in addiction recovery become more aware of their thoughts, feelings, and behaviors. This awareness is essential because it can help them recognize when they are at risk of resuming use, and take proactive steps to avoid it.
Reduced Stress: Stress is a significant risk factor for resumption of use, and having the ability to cope with it can help individuals stay on the path of recovery.
Increased Resilience: Resilience can help patients bounce back from setbacks, cope with challenges, and stay committed to their recovery goals.
Enhanced Social Support: Practicing recovery coping skills can help individuals in addiction recovery connect with others who share similar struggles. This social support can be a valuable source of encouragement and motivation, especially during difficult times.
Improved Emotional Regulation: A patient's ability to regulate their emotions is crucial because it can help them avoid impulsive behavior and make better decisions.
Increased Confidence: Patients who have practiced skills like assertive communication, setting boundaries, and breaking down goals, and even been through role-plays for real-life challenges they need to face, such as a job interview, will have increased confidence when it counts.
Breaking a bad habit can vary in time depending on the person, the habit itself, and the efforts made to change the behavior. Research suggests that it can take anywhere from 18 to 254 days for a person to break a bad habit, with the average time being around 66 days (Gardner & Wardel, 2012; Lily et al., 2010).
However, it's important to note that this timeline is not set in stone and can vary significantly depending on factors such as the complexity of the habit, the individual's level of motivation, and the amount of effort put into breaking the habit.
Breaking a habit can be challenging, but it's not impossible. The key to success is to remain committed and consistent in making changes to behavior. This involves identifying triggers or cues that lead to the habit, developing alternative behaviors, and practicing them consistently over time. The identification, development of alternative behaviors, and practice are ideal for therapy, where they can be done in a safe and controlled environment.
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It's also important to note that, while setbacks can occur and are a natural part of the process, the other side of that coin is establishing good habits, which shares an identical timeline and potential for influence; both require consistent effort and commitment over time. To create a new habit, one must identify the desired behavior, set a specific goal, and make a plan to integrate the behavior into their daily routine. It's essential to start small and gradually increase the level of difficulty or frequency of the behavior over time. Therapists can help their patients achieve their goals through effective delivery of therapy.
It's important to track progress, reward oneself for small successes, and remain flexible in adjusting the plan as needed, as it is to recognize that setbacks and occasional slip-ups are a natural part of the process, though that doesn’t mean they must happen. It is essential to be kind to oneself and keep moving forward. If someone hasn’t used for 19 days, and they return to use, there isn’t a hard reset; they don’t go back to zero. The progress made over those 19 days does not disappear. The positive thought patterns and behaviors established over the 19 days, the neural pathways of the procedural learning system, will be easier to access and utilize. Like breaking bad habits, clinicians, patients, and all humans have influence and a level of control over that timeline (Gardner & Wardel, 2012; Lily et al., 2010).
In addition to repeated practice, there are ways to speed up the rate at which patients form new positive thought patterns and behaviors, one of which is active engagement, or conscious attention. It is a critical component of the learning process as it enables individuals to selectively attend to information that is relevant, process it deeply, and integrate it with prior knowledge. It also supports cognitive flexibility, metacognition, deeper learning, and self-regulation.
Conscious attention allows individuals to reflect on their own thinking processes, identify their strengths and weaknesses, and adjust their learning strategies accordingly. By cultivating conscious attention skills, individuals can enhance their ability to learn, adapt, and grow throughout their lives (Schraw & Dennison, 1994; Diamond, 2013; Freeman et al., 2014).
Another factor is patient talk-time. Multiple studies show that patient talk time is an important factor in therapy outcomes. For example, Kivlighan et al. (2018) found that the amount of client talk time was positively associated with the therapeutic alliance and treatment outcome, and Orlinsky et al. (1994) found that patients who talked more in therapy tended to have better outcomes.
Levitt et al. (2016) found that a dialogue-based intervention that emphasized patient talk time was effective in reducing symptoms of post traumatic stress disorder.
Miller (2014), found that increases in positive change talk lead to a reduction in patient resistant behaviors and improved outcomes.
Finally, Arnow et al., (2013) found that both patient and therapist involvement, including patient talk time, were related to treatment outcomes in psychotherapy with chronic depression.
Ending Where We Began
Reimbursements and the problems that arise while negotiating with payers.
Clinical burnout that leads to turnover.
Turnover that leads to staffing shortages.
Patients re-entering treatments at rates of 30% or higher year over year.
These are common pain points across the behavioral health and addiction treatment field. While discussed often, solutions have been few and far between. Not anymore. Organizations can adapt and incorporate evidence-based solutions to not only address these obstacles but enhance their levels of care, become a differentiator in a saturated market, and thrive as a forward-thinking, data-driven, life-saving business that fulfills their mission.
Set your organization up for success by investing in your staff so they are trained to deliver the absolute best care possible with up to date, accurate data to guide them.
Through effective delivery of therapy and utilization of recovery capital skill-building , patient outcomes will improve and we will move closer as an industry in fulfilling our mission to break the cycles of generational trauma and help more people heal and find lasting recovery.
Ready to move into the future of treatment and ensure the sustainability of your program? Contact us at certification@grouptherapycertification.com or call 657-360-4114.
Auditing and Optimization Package
Regular auditing and supervision of sessions is a critical component of any effective program. Most programs have regular supervision and group audits built into their SOPs, but the reality is that they are rarely implemented. The day to day of treating patients can be all consuming with supervision being the first thing to get dropped.
Additionally, measurement-based care is a new initiative in the fields of behavioral health and SUD, one that many clinicians are not only unfamiliar with, but also have some anxiety around. In order to continuously improve as an overall program as well as to help clinicians improve, patient outcomes tracking provides the backbone to continuous improvement and validation of program efficacy.
Comprehensive Supervision Implementation
The Institute has a robust process for implementing and facilitating regular session audits combined with feedback sessions in order to help counselors and therapists become the best they can be, ensuring sustained and continuing improvement for patient outcomes.
Our auditors are expertly trained in not just engaging and effective session delivery, but also in the art of effective feedback delivery. When it comes to the practice of therapeutic interventions, clinicians can, understandably, be very sensitive. If constructive feedback in particular is not presented correctly, clinicians will not be receptive and may even become resistant to coaching and development. This is why the team here at the Institute not only comes alongside your team during audits and feedback delivery, but actively coaches your team to be able to present feedback in a way that will be well received and, therefore, effective.
The Institute will:
● Provide audit forms if not already in place.
● In conjunction with the Clinical Director or Clinical Supervisor, communicate and implement regular audit schedule for all clinicians at the facility.
● Conduct bi-weekly group audits and feedback sessions in conjunction with the Clinical Director, Supervisor, or relevant staff member (via remote live stream).
● Align on feedback and provide coaching related to feedback delivery to Clinical Directors, Supervisor, or relevant staff member (via remote live stream).
● Perform one onsite visit per year at minimum to provide feedback, maintain certifications, and deliver a refresher session if required.
● Train and support clinicians on the implementation of measurement-based care. MBC will be incorporated into all audit and feedback sessions. (If a robust, automated patient outcomes tracking system is not already in place, we partner with ERPHealth to setup and provide such a system).*
● Collaborate with Clinical Director or other relevant staff member to develop targeted trainings to clinical team based on observed gaps or areas for improvement.
● Handle all tracking and record keeping related to audits and supervision.
● Monthly reports to the executive team on sessions audited, areas for improvement, trainings conducted, and patient outcomes.
● Create dashboards and provide regular reporting to the executive team on both compliance and individual clinician's progress*
● In conjunction with patient outcomes data, provide analysis comparing individual and facility-level session delivery progress with patient outcomes gains.
* Optimization Package Only
References:
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