Revolutionizing Substance Abuse Treatment with Stages of Change and Motivational Interviewing
Organization Name:
Community Name:
Organization or Community Type:
What was the criminal justice problem facing the community?
Description of Problem:
According to the 2011 Crimes in Maryland Report, Carroll County leads the state with the lowest serious crime rate among 23 counties. However, according to the report, drug arrests increased in Carroll County from 2010 to 2011. In 2011, 692 individuals were arrested for drug offenses, compared to 640 arrests in 2010. Approximately two-thirds of local offenders are incarcerated for substance abuse crimes or for petty thefts committed to support substance abuse habits. To address these issues, the Carroll County Health Department (CCHD) sought to implement the Stages of Change program and the Motivational Interviewing approach as a new response strategy.
What factors were contributing to the criminal justice problem?:
Based on data provided by local law enforcement, below are the contributing factors to Carroll County’s criminal justice problem:
- Increase in availability of illegal drugs
- Easier access to prescription drugs
- Economic hardships facing the community
Criminal Justice Topic area:
Crime Justice Sub-Topic area:
Which evidence-based solutions were recommended for this problem?
Name of evidence-based program or practice:
Description of Evidence-Based Program or Practice:
The Carroll County Health Department (CCHD) adopted the Stages of Change program to restructure the process and methods used by the Drug Treatment Court System for treating substance abusers. The Stages of Change program stresses the importance of determining where an individual is in the process of change to best match that individual to interventions and strategies that will assist him or her in making the cognitive change from an abuser to a non-abuser. Program participants are provided with specialized group and individual therapy based on their particular needs and situation. Many participants receive individual therapy in the form of Motivational Interviewing, a client-centered approach to assist people in working on their ambivalence about changing their behavior and uses empathetic listening to engage a person in recognizing that their current behavior is a contributing factor to their inability to achieve their desired goals.
Proponents of the Stages of Change program believe that considering the patient’s readiness to change his or her behaviors, understanding the barriers to change, and helping practitioners recognize the triggers that result in a relapse can improve patient satisfaction and increase chances of successfully making a change. The program recognizes that mandating a patient to terminate drug abuse without understanding both the individual’s stage of readiness and the factors that contribute to his or her substance abuse will not result in successful treatment. Using the Stages of Change program coupled with Motivational Interviewing, CCHD assists Drug Treatment Court participants to assess the pros and cons of changes that need to be made.
How was the evidence-based solution implemented?
Response Strategy:
With grant funding, Carroll County was able to expand on its initiative to integrate substance use disorder programs and mental health programs. As a part of this initiative, a group of behavioral health providers developed a collaborative consensus document, which included joint foundational beliefs and guiding principles for meeting the needs of the person with co-occurring substance abuse and mental health disorders.
- Peer-to-Peer Relationship Building: Carroll County’s behavioral health providers reached out to the Network for Improvement in Addictions Treatment (NIATx) for training in new methodologies addressing substance abuse. Practitioners received training in Stages of Change and Motivational Interviewing, which focused on the process of change and change leadership. This training helped practitioners launch a strategy in which substance abuse and mental health providers collaborated to address the needs of participants of the Drug Treatment Court.
- Interagency Collaboration: Carroll County conducted a “kick-off” meeting to convene mental health and substance abuse providers and practitioners to discuss the integration of behavioral health and substance abuse treatment. Participants outlined the next steps to fully implement the Stages of Change program and Motivational Interviewing approach. Each agency was asked to perform a COMPASS-EZ self-assessment to define the baseline of how the agency rated against specific performance indicators prior to any new training. Then at set internals, CCHD could measure the progress of these agencies against these indicators to gauge program quality and impact over time.
- Client-Focused Training: Carroll County trained local community providers to recognize a client’s readiness stage and place them in specialized intervention programs based on their individual ability to accept treatment. Participants are screened to identify peripheral issues that may be related to their substance abuse. If these contributing issues are not detected early on, there is a greater chance that the individuals participating in drug rehabilitation programs will relapse because of a failure to address the root cause of their problems.
- Motivational Interviewing Training: These providers were also trained in Motivational Interviewing, a critical component of the Stages of Change program to encourage and push participants to make the changes necessary to address the issues in their lives. Interviewing training occurs one day per month, and about $10,000 is being spent to train 125 supervisors and clinicians. Supervisory staff are learning how to train new frontline clinicians in Motivational Interviewing. The use of local providers to train others reduces costs by eliminating the need for multiple trainings from the original provider and helps community providers be self-sufficient in implementing and continuing these programs. Additionally, Carroll County plans to host annual training on evidence-based practices for newly hired staff to ensure Stages of Change and Motivational Interviewing has longevity.
Stakeholder Groups Involved:
Stakeholder Groups Involved:
Stages of Change and Motivational Interviewing engages mental health providers and substance abuse practitioners to target individuals who have been chronically involved with law enforcement and court systems for multiple drug-related offenses. In general, these individuals are facing 10 or more years of jail time for crimes that were either committed under the influence of drugs, or were motivated by a need for money to buy drugs.
Estimated Cost to Implement:
The Carroll County Health Department spent approximately $10,000 to train 125 supervisors and clinicians in Motivational Interviewing for substance abuse patients.
Estimated Time to Implement:
Impact and Outcomes
Since implementing Stages of Change and Motivational Interviewing began nine months ago, outcomes to date are qualitative rather than quantitative. CCHD used Motivational Interviewing to achieve immediate impact by provoking staff to reassess their initial thinking and approach toward addressing the rehabilitation of substance abusers. There was a recognition of flaws in the former model, which perpetuated the idea that substance abusers had to hit rock bottom in order to develop the impetus for improving their lives and reducing their reliance on drugs. The staff now understand that drug abusers have peripheral issues that were not being expressed or addressed.
Prior to program implementation, significant challenges existed in delivering treatment to patients. For example, Drug Treatment Court participants often failed to appear for scheduled sessions and no follow-up was conducted to ask why. As a result of completing training, staff conducted assessments to determine the cause of patient failure to appear. Often, they determined that patients lacked transportation to attend meetings and were often embarrassed to ask for travel vouchers. With this newfound understanding, CCHD staff implemented a peer network enabling individuals in recovery to reach out to patients to ensure meeting transportation was available and to encourage meeting participation. Individuals in the peer network were also trained to help participants fill out complex forms for health benefits. Through respect and empathy for substance abusers, and a recognition of issues that are related to drug abuse, CCHD staff have adopted productive and meaningful ways to connect with their patients and help them with their problems.
Although full implementation only began in August, CCHD is already looking to implement a strength-based assessment tool to enable staff to follow the model in a more structured manner. CCHD is also planning supervisory training around the issue of adherence to the model, as well as sustainability and maintenance of the model. CCHD has already realized the largest shift in the attitudes and acceptance among the professionals working with the participants. Staff now have a better understanding of how to acknowledge that patients have choices, while also ensuring those choices are informed, helps patients to achieve real, sustainable change. These patients have shared that this new approach enables them to feel more empowered and involved in the process of change.
While Carroll County is still in the early implementation phase of this program, there are a number of considerations that can guide the evaluation of this, and other drug court programs. There are almost two decades’ worth of quasi-experimental and experimental evaluations of drug court programs. These evaluation studies measure outcomes for participants including: recidivism (defined as further incarceration), return to drug use, re-arrest, and re-conviction, among other measures. The methodological strengths and weaknesses of studies in this field vary and contribute to inconsistent findings of positive outcomes achieved across those courts studied. (See the Campbell Collaborative Review of this topic). Drug Court developers should review research literature in this field to facilitate the selection of outcome measures and study designs that will help them determine if their investment in drug court programing is having the intended effect(s).
For more information, see these studies:
- Deschenes, EP, S. Turner, et al. (1996). An experimental evaluation of drug testing and treatment interventions for probationers in Maricopa County, Arizona, RAND Santa Monica, CA.
- Gottfredson, Denise C. , Stacy S. Najaka, Brook W. Kearley, Carlos M. Rocha. (2005). “Long-term effects of participation in the Baltimore City drug treatment court: Results from an experimental study.” Journal of Experimental Criminology, Spring 2005, 2(1):67-98.
- Ojmarrh Mitchell, David Wilson, Amy Eggers, Doris Layton MacKenzie. (2012). Drug Courts’ Effects on Criminal Offending for Juveniles and Adults. The Campbell Collaboration. Accessed 11/1/2013 at http://campbellcollaboration.org/lib/project/74/.
- Shanahan, M., E Lancsar, M Haas, and B Lind. (2004). Cost-effectiveness analysis of the New South Wales adult drug court program. Evaluation Review. 28(1):3-27.
Lessons Learned
- Evidence-based practices and programs take a significant time to implement and cannot become fully integrated overnight. Jurisdictions should plan for implementation over a lengthy period time, and include measures to reduce reliance on external provision of services.
- In order to develop an action plan, communities should perform a self-assessment to determine the baseline knowledge and performance of substance abuse and behavioral health providers. Clinicians and professionals working in rehabilitation and therapy should understand the linkages between substance abuse and mental health.
- It’s important to train all community providers on evidence-based practices being implemented because Drug Treatment Court participants attend substance abuse and/or behavioral health treatment at many facilities.
- Treatment and/or care providers need to understand the peripheral issues patients struggle with that contribute to or aggravate their substance abuse. Once providers reach this understanding they can more productively help their patients find the self-motivation that is needed to make the necessary changes in their lives.
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