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Addiction Recovery for Moms (ARMS) is a nonprofit, outpatient substance abuse treatment program located in Ventura, CA, for women residing in Ventura County. The program has been in existence for 10 years and offers alcohol and drug assessment and individual and group therapy for women, ages 18 and over, who are pregnant, have children under age 17, or are attempting to regain legal custody of their children. Their mission is to foster hope, resiliency, and recovery for their clients and the clients’ families by providing the highest quality of prevention, intervention, treatment, and support. Their services strive to be client- and family-focused, accessible, culturally-competent, age-appropriate, cost-effective, and outcome driven. They address the special needs of women with children using a multidisciplinary team of alcohol and drug counselors, licensed clinicians, community services coordinators, the clinical administrator, and the staff psychiatrist. In addition to individual and group counseling, they also offer an intensive perinatal program, methamphetamine intensive program, recovery group, relapse education, crisis intervention, mental health assessment and referrals, and a recently added co-occurring disorders program. Pregnant women who are injection drug users and substance users are given priority admission to the program above non-pregnant women who use injection drugs or substances. ARMS operates under the following values: respect for diversity, the individual, and each other; excellence to be achieved by personal and organizational accountability; leadership through innovation and collaboration; integrity as evidenced by open and timely communication and unquestionable ethics; and commitment to proven, high quality care. Their number one goal is to help women achieve and maintain sobriety in order to deliver healthy babies and reunify with their children.
Beginning in June 2016, ARMS launched a pilot program to offer integrative mental health and substance abuse treatment utilizing doctoral level practicum students as a cost-effective way to offer better quality services and quicker time to treatment. Prior to 2016, clients meeting requirements for mental health services were referred out but often did not follow up because initial appointments were not available for 60 days due to the high demand for these services. As a result, many of these clients relapsed or dropped out of the program altogether. In June 2016, two doctoral practicum students, under the supervision of the clinical psychologist, were added to the team to provide individual psychotherapy to approximately 40 clients throughout the year and gather research data about the effects of adverse childhood experiences on adult functioning. Most of the clients had diagnoses such as Posttraumatic Stress Disorder, Major Depression, and other Anxiety Disorders. ARMS believes this program is successful but needs the data to support their claim and justify its continuation. ARMS’ grant writer typically does this work but is currently on maternity leave and ARMS’s board of directors need to make a decision about continuing this program within the next 120 days. Thus, ARMS wants an independent contractor to evaluate their program and let them know if it worked, i.e., were clients able to receive mental health services in less than 60 days and did the received services improve clients’ overall mental health functioning. They have also indicated they would be open to any other useful information that comes to light as a result of this study.
Although the company is capable of doing their own program evaluation, they have indicated they do not have the time to do so. Thus, my role in this case is to act as an external consultant to ARMS, specifically interacting with their consultee, Dr. David, clinical psychologist, and, at times, interacting with other staff, doing those tasks they do not have time to do. I have been chosen for my subject matter expertise as a clinical psychologist with an extensive background working in the addiction field. Unlike the work of a therapist or supervisor, my work as a consultant for ARMS is to work with this multidisciplinary team to address a community need, rather than an individual need, and to advocate for this underserved population of addicted mothers by enhancing and supporting effective interventions. In doing so, my role as evaluator will change throughout the stages of the evaluation. Initially, I will work as the expert or judge to identify credible data about the effectiveness of the integrative services based on the information the stakeholders give me; as a methodologist when collecting, assessing, and interpreting the data; as a program facilitator during the implementation of the evaluation; and an educator when giving the results back to ARMS in a manner that is understandable. Since I will be doing a considerable amount of the work, I expect a peer relationship and frequent interaction with the staff, clinicians, and administrators as I learn what data I need to gather, from whom I need to gather data, what data exists, and where the data is located.
Utilizing a practice-based participatory research paradigm, I aim to adapt and merge with the culture of the organization in order to build the logic model and data plan around their input by allowing them to define what is meaningful to make the results of the study useful for them. This can be accomplished by assessing the evaluand within the values of the stakeholders. In this case, the evaluand is the effectiveness of the integrative services program, and the stakeholders include the clinic administrator, the clinical psychologist, the psychiatrist, the substance abuse counselors, the practicum students, the clients, the clients’ families, the public, and the board of directors. Since there is a time consideration and ARMS wants to know about the effectiveness of their new program, I will include the clinic administrator, clinical psychologist, psychiatrist, substance abuse counselors and practicum students in the initial discussion to develop a consensus about what exactly we are going to measure at this time, as these are the individuals with whom I will need to gather information and work closely.
Logic Model and Data Plan (See Appendix)
ARMS’ logic model was defined by the stakeholders (i.e., the clinicians, psychiatrist, clinic administrator, practicum students, and the clinical psychologist) at the first meeting in answer to the following questions: What do you want your program to do? How will you know if you accomplished your goal?. There is consensus among the ARMS’ professionals that helping these women successfully complete the program and never return because they learned new skills to manage their emotions and remained clean and sober would be ideal, as many of the clients have been through the program before. As for the clients, there is a consensus of what they want based on the reasons they list for seeking mental health treatment: a better understanding of self, ability to cope without using drugs, and getting their kids back. The substance abuse and mental health therapists both agree that the women often cite an inability to manage their emotions as one of the major reasons for relapse, and would like to address that component, as they believe if the women can effectively regulate their emotions, they will not relapse.
To that end, ARMS’ mission is to help women achieve and maintain sobriety in order to deliver healthy babies and reunify with their children. The group agreed in order for mother’s to reunify with their children, they have to be clean and sober, complete mandated classes, learn how to effectively manage their emotions, and process past traumas. Thus, according to input from the stakeholders and in accordance with the organization’s mission, ARMS has two main goals: provide mental health services, provide substance abuse treatment. Their logic model then is to decrease clients’ substance abuse and improve their mental health by providing integrative treatment for both disorders simultaneously. The clinical psychologist and psychiatrist are both experts in substance abuse treatment and have been working in the field of addiction and recovery for over 35 years. Both agree that the best practice for successfully treating substance abuse includes integrative mental health and substance abuse treatment per the American Psychiatric Associations treatment recommendations (2006) as many clients with dual disorders are doomed to poor treatment course, higher rates of relapse and hospitalizations following traditional methods. The traditional methods of sequential and parallel treatments fall short of ARMS goals because the former creates confusion as to which disorder to treat first, leaving the untreated disorder to worsen; and the latter causes the client to integrate their own care as different treatment providers use different treatment philosophies, often failing to communicate about their client and provide coordination of services.
The clinical psychologist and the practicum students also noted that a significant number of the clients have experienced a high number of adverse childhood experiences which research shows leads to a 4- to 12-fold increase for alcoholism, drug abuse, and depression. They agreed that the impact of these adverse childhood experiences, although accounting for some of the current substance abuse, would not be sufficiently treated in a substance abuse only curriculum. The substance abuse counselors indicated that ARMS is an abstinence-based treatment program as abstinence has a higher remission rate than harm reduction. They also indicated that random weekly UAs to test for the presence of substances was a good way to verify if the women are staying clean and sober. The clinic administrator was interested in the bottom line and suggested discovering time to service by comparing the date mental health services are requested to the date of the initial mental health assessment intake. Her thinking was that the quicker clients get into needed services, the more income is generated through the use of those services.
Since this is a pilot program, the clinical psychologist was astute enough to gather data on all the clients from the start. He gave every client that enrolled in substance abuse treatment the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) to establish their baseline symptomology of anxiety and depression, and then again every 30 days to monitor their levels until client terminated. He also gave every mental-health-services-referred client the Adverse Childhood Experiences (ACE) questionnaire, the modified International Violence Against Women Survey (IVAWS), the BDI, the BAI, and the Relapse Scale. He used the ACE to assess for the number of adverse childhood experiences, the IVAWS to assess for the number of adverse adult experiences, and the Relapse Scale to assess the reasons for the client’s most recent relapse. All measures were given at intake to establish the client’s baseline functioning, with the BDI and BAI being administered and scored again every 30 days until client terminated from services. The practicum students suggested using the BDI and BAI scores to assess the reduction of symptoms as both inventories have high reliability and validity for measuring symptoms associated with depressive disorders and anxiety disorders, respectively.
Thus, ARMS’ logic model depicts two main areas for helping addicted mothers achieve and maintain sobriety to deliver healthy babies and/or be reunited with their children: 1) decrease substance abuse and 2) improve mental health. Efforts to decrease substance abuse are targeted to the clients, drug counselors, and clinic administrator. The clients must attend alcohol and drug program (ADP) classes, individual drug counseling, and submit to random UAs. The drug counselors have to provide certified drug counseling curriculum in the classes and individual sessions and administer the UAs. The clinic administrator has to bill for services which generates the income that supports the treatment program. In an effort to improve client mental health, the substance abuse counselors refer their clients for individual therapy provided by the practicum students, who are supervised by the clinical psychologist. The practicum students administer, score, and log the Beck’s data to monitor client symptoms in addition to providing psychoeducation and interventions utilizing evidence based practices such as Motivational Interviewing CBT and Seeking Safety. The psychiatrist provides a medication evaluation, prescribing meds if warranted, for every client referred to mental health from the substance abuse counselors.
Since this program evaluation is looking at a year’s worth of existing data, Dr. David has agreed to be the point person. He will instruct his students to ensure their clients’ Beck’s, ACE, IVAWS, and Relapse Scale data is complete and accurate and listed on the shared drive by 2/28/17. By the same date, Dr. David will ensure those measures are accurate and listed on the shared drive for those individuals who just received substance abuse treatment. For the students and Dr. David, this means they will check the hard copies of their data against the data listed in the shared drive. After the information is verified, they can put a check mark on the hard copy and write verified at the top and the place the sheet into the data folder in the file room. By 3/6/17, Dr. David will tally the data for the items endorsed on the ACE, IVAW, and Relapse Scale measures creating a percentage for the most frequently endorsed items and place that information on the shared drive. The practicum students will also count the time it took for clients to get an intake from the time the clients were referred. This information will be placed under each client’s numerical ID on the server. Dr. David will then average all the times to measure how long clients are actually waiting for services. I will then cull the data from the shared drive comparing pre and post treatment BDI and BAI scores for the integrative services group versus the substance abuse only group to see if the integrative services made a difference. Specifically, I will employ a document review of pre and post treatment self-report measures .
Mock Results and Discussion
The following results were presented in a formal written report and delivered to the board of directors. The results showed that utilizing integrative treatments does improve overall mental health functioning. Clients receiving integrative mental health and substance abuse treatment had reduced BAI and BDI scores at end of treatment equivalent to those receiving substance abuse treatment only. All clients entering the substance abuse program were given the BAI and BDI to assess baseline symptomology of anxiety and depression. Clients referred to mental health treatment by their substance abuse counselors had initial scores that were 10-15 points higher than those not referred to treatment. These individuals who were referred were in the moderate to severe range of symptoms on both measures. The average length of treatment was about 160 days, or 6 months, with some client’s terminating after 240 days. Of note was that clients who remained in treatment longer had a larger reduction in symptoms over time; thus, the longer one remained in therapy, the better their outcome seemed to be.
When compared to those who received substance abuse treatment only, the integrative mental health and substance program clients had 20% fewer positive UAs for the year. This suggests that psychotherapy targeting mental illness in conjunction with concurrent substance abuse treatment has a positive effect on the relapse rates of mothers in the ARMS program. As for time to service, utilizing volunteer practicum students decreased the time to service from 60 days to 20 days. First contact by the mental health provider averaged one week from the time the referral for services was made but scheduling conflicts and missed appointments by the client lead to a longer delays between initial request and actual intake. Thresholds were set for the outcomes evaluated and ARMS was encouraged to continue to gather data throughout the coming year to match or better the thresholds.
On a side note, with all the data Dr. David and his students have been accumulating over the past year, a few unexpected results showed up. For example, when averaging the total ACE and IVAWS scores, it was noted that 71% of their clients had ACE scores of 4 or higher and 85% had scores of 4 or higher on the IVAWS. This maps onto the current literature concerning the effects of adverse childhood experiences on adult functioning which shows that experiencing 4 or more adverse events as a child leaves one vulnerable to risk of alcoholism, drug abuse, depression and other adverse experiences as adults. Also noteworthy were the percentages of the most frequently endorsed relapse factors which included in order of severity: struggling with emotions, relationship conflict, and family crisis. Again, the results match with the research literature on substance abuse that show individuals with co-occurring disorders experience deficits in their ability to relate interpersonally. What this analysis shows is that ARMS is definitely targeting the right population and utilizing appropriate evidenced-based practices for their clients.
What it also indicates, however, is that the ADP counselors are right, the client’s need more help with regulating and coping with their emotions in order to boost their overall interpersonal functioning. For that reason, it was suggested to ARMS that the implementation of a conflict resolution and affect regulation group intervention could be beneficial to helping their clients achieve sobriety, remain sober, and reunify with their children. Groups such as these have shown efficacy for assisting client’s with PTSD and histories of childhood abuse in learning effective emotional coping skills and assertive communication techniques to enhance their ability to have supportive sober relationships.
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