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Select and describe one evidence-based substance abuse treatment and one prevention program from the Substance Abuse and Mental Health Services Administration website. Explain how you would apply this intervention to a population you plan on working with as an addiction professional.

Explain the strengths and limitations of each program.

Explain any insights you gained from evaluating these treatment programs.

Assignment: Evidence-Based Substance Abuse Treatment
and Prevention Programs
For a treatment program approach to be classified as evidence-based, it must include
strong theoretical foundations. It must also provide sound empirical evidence of
For this Assignment, you evaluate evidence-based programs and non-evidence-based
programs. In addition, you analyze their strengths and limitations in supporting recovery.
Use the Substance Abuse and Mental Health Services Administration website or
other reputable sources. https://www.samhsa.gov/resource-search/ebp
In a 2 page APA-formatted paper, address the following:
Select and describe one evidence-based substance abuse treatment and one
prevention program from the Substance Abuse and Mental Health Services
Administration website. Explain how you would apply this intervention to a
population (addicted Juveniles or incarcerated addicts) you plan on working
with as an addiction professional.
Explain the strengths and limitations of each program.
Explain any insights you gained from evaluating these treatment programs.
, VOL. , NOS. -, –
In Search of Evidence-Based Treatment in TCs for
Addictions:  Years of Research in TC De Kiem (Belgium)
Wouter Vanderplasschena , Stijn Vandeveldea , Clara De Ruysschera ,
Dirk Vandeveldeb , and Eric Broekaertc,∗
Department of Special Needs Education, Ghent University, Ghent, Belgium; b De Kiem, Therapeutic
Program for Drug Users and Their Families, Gavere, Belgium; c Ghent University, Department of Special
Needs Education, Ghent, Belgium
Despite more than 40 years of research, limited evidence is available for the effectiveness of drug-free therapeutic communities
(TCs). Worldwide, TCs have attempted succesfully to integrate
innovative and evidence-based interventions, while adhering to
the “community as method” (De Leon, 2000). This article is a case
study of scientific research on practice and innovations in a TC, De
Kiem (Belgium), over the past 40 years, illustrating how research
and innovative approaches have shaped the TC into its current
practice. From the start, scientific research was used to develop
and adapt the TC program. International collaboration introduced
new ideas, instruments, and methods and promoted a culture
of inquiry. Several interventions that were implemented have
contributed successfully to increased program retention, like the
introduction of a welcome house phase, social network support,
and a mother and child program.
Therapeutic community;
substance abuse; recovery;
research; intervention;
residential treatment
The TC method
Drug-free therapeutic communities (TCs) are one of the longest standing types of
treatment modalities for drug addicts (Vanderplasschen, Vandevelde, & Broekaert,
2014). Their start dates back to 1958, when an utopic drug-free and self-supporting
community of ex-addicts, Synanon, was founded in Santa Monica, California.
The Synanon model quickly spread across the United States and gave rise to the
first concept therapeutic communities like Daytop Village, Phoenix House, and
Odyssey House (Broekaert, Vanderplasschen, Temmerman, Ottenberg, & Kaplan,
2000; Goethals, Soyez, Melnick, De Leon, & Broekaert, 2011). Soon, TCs were
implemented in Western Europe and the model spread across the globe. These drugfree peer-led environments adopted Synanon’s hierarchical structure (“the triangle”)
and therapeutic techniques (“the circle”). A three-stage treatment model (detoxification, treatment, reintegration) was introduced, which served as an example
CONTACT Wouter Vanderplasschen
Department of Special Needs Education, Ghent University, H. Dunantlaan , B- Ghent, Belgium.
∗ Eric Broekaert passed away in September . Ghent University was his affiliation at that time.
©  Taylor & Francis Group, LLC
for many residential treatment programs to date (EMCDDA, 2014). Drug-free or
concept therapeutic communities, later called TCs for addictions (De Leon &
Ziegenfuss, 1986), have been defined as “drug-free environments in which people
with addictive problems live together in an organized and structured way to promote change toward a drug-free life in the outside society” (Broekaert, Kooyman,
& Ottenberg, 1998, p. 595). Clearly, not all residential treatment programs are TCs,
nor are all TCs organized in residential settings (Broekaert, Raes, Kaplan, & Coletti,
Effectiveness of TCs
Despite more than 40 years of research in drug-free TCs, limited evidence is available for their effectiveness. An outdated Cochrane review (based on randomized
controlled trials [RCTs] published prior to 2004) concluded that there was little
evidence that TCs offer significant benefits in comparison with other residential
modalities or that one type of TC is better than another (Smith, Gates & Foxcroft,
2006). Also, a review of longitudinal studies in community-based TCs (excluding
findings about prison TCs) did not demonstrate convincing results (Malivert, Fatséas, Denis, Langlois, & Auriacombe, 2011). The authors found evidence for a drop
in drug consumption after TC treatment, but long-lasting benefits were uncertain.
Other systematic reviews about TCs for addictions yielded more positive results:
Lees and colleagues (2004) concluded that concept TCs generated better outcomes
than democratic TCs, which was explained primarily by differences in problem
severity at treatment entry. Similarly, a recent review of 16 controlled TC studies
(Vanderplasschen et al., 2013) showed that the vast majority of these studies demonstrated significantly better substance use and legal outcomes on at least one followup moment among the TC group. However, the need to prove the effectiveness of
this long-standing treatment model remains, in particular because TCs have been
criticized for their high drop-out and relapse rates, high costs and lengthy treatment
episodes and relatively low number of treated individuals (Vanderplasschen et al.,
George De Leon, a lifetime TC researcher and advocate, has refuted the assertion
that there is no or little evidence for TC treatment. Acoording to De Leon (2010),
different types of empirical studies (not only RCTs) and systematic reviews have consistently shown that TCs produce beneficial effects among TC graduates. He argued
that TCs have attempted succesfully to integrate innovative and evidence-based
interventions like motivational interviewing and relapse prevention techniques to
optimize the community as method approach (De Leon, 2000). Other experts have
stated that it is nearly impossible to prove the effectiveness of a comprehensive and
holistic treatment system like a TC, as is the case with psychiatry and education as
general terms (Broekaert, Vandevelde & D’Oosterlinck, 2013). Despite this limitation, thousands of TCs worldwide have continuously searched to improve treatment
outcomes, while sticking to the community as method and introducing innovative
Aims of the article
An example of a TC with a long treatment and research history that has implemented several innovations while respecting the community as method, is De Kiem
in Belgium. The TC was founded in 1976, based on experiences of American and
European precursors and emerging theoretical insights. It was adapted throughout the years to meet new challenges and integrate innovative ideas, while adhering to the original model and monitoring effects of innovations through scientific
research. De Kiem started as a small-scale TC inside a psychiatric hospital with a
total capacity of 20 beds. Currently, De Kiem is a large-scale organization, including a therapeutic community of 35 beds and a continuum of services consisting of
outpatient facilities, a welcome house, mother and child services, and prison-based
The aim of this article is to describe De Kiem as a case study to illustrate how several studies and innovations over the past 40 years have shaped TC treatment in De
Kiem into its current practice. We do so by highlighting the role and outcomes of scientific research in De Kiem, discussing past and future challenges and introducing
some directions for future research. Ultimately, we aim to provide TC practitioners and researchers insight in pathways to build evidence-based TC practices and
generate knowledge in TC environments.
The start of De Kiem
The early years
The foundation of De Kiem goes back to a master dissertation by a student in psychology and educational sciences, Eric Broekaert (1972), who would later become
the first director of the TC. He accomplished an internship at Centrum Linnaeus
Parkweg, a department located inside the famous Jellinek clinic in the Netherlands,
and interviewed several residents about the circumstances that had contributed to
their addiction (Broekaert, 1972). However, it was not the dissertation in itself that
led to the establishment of De Kiem, but rather the meeting with the psychologist
supervisor, Henri Boulogne. The latter followed a training and workshop by Dan
Casriel, who was well-acquainted with the functioning of Daytop Village New York,
the first drug-free TC in the United States (Casriel, 1972). The interest in the TC
concept was born and later that year Eric Broekaert started a PhD-study on therapeutic communities. The dissertation was supervised by Maria Wens, the leading professor in Special Needs Education (Orthopedagogics, or Orthopedagogiek
in Dutch) at Ghent University, Belgium. The immediate cause for the foundation of
De Kiem in 1976 was the fact that Wens wanted the study to be rooted in practical experience. After gaining experience with the TC concept by visiting Synanon
and several American TCs (Last Renaissance in Washington; Odyssey House in
New York; Delancy Street in New York), the board of directors of the psychiatric
clinic where Eric Broekaert was employed granted permission to start a drug-free
therapeutic community. The TC had to be developed within the walls of the hospital, in an old chapel and sleeping site on the first floor. Three years later, the
last patients left the clinic and the TC moved to a separate accomodation in a
small village in the neighborhood. In his dissertation, Broekaert (1980) studied the
history, philosophy, and functioning of the TC as an educational and therapeutic
The treatment model
Treatment in De Kiem was seen as a unique combination of having a structured daily
life and taking part in encounter groups, which focused on open emotional expression within a safe and open climate. As these essential elements of TC functioning
correspond with the primary characteristics of educational acting (Broekaert, 1993),
the theoretical background of the treatment approach in De Kiem was found in personalism (Kohnstamm, 1947). Personalism influenced Van Houte, the first professor in Special Needs Education in the Low Countries, and Broekaert and colleagues
brought these theories and thoughts on education into practice in the therapeutic
One of the studies in Broekaert’s dissertation (1980) focused on the communication structures between residents and staff in the TC by means of a thematic
analysis. Also, as a first test of effectiveness, he conducted a follow-up study of the
first 40 residents admitted in De Kiem. One year after admission, 24% of the sample was free of drugs, and of the 15% that had stayed in close contact with the TC,
no one relapsed (Broekaert, 1980). These outcomes were similar to those of other
studies that demonstrated that a third of TC residents did not relapse, a third had
mild relapses, and another third relapsed severely (Zimmer-Höfler, Dobler-Mikola,
Uchtenhagen & Christen, 1994; Broekaert, Vandevelde, Vanderplasschen, Soyez &
Poppe, 2002). These key findings about TC treatment in De Kiem were not only published as a scientific monograph, but were—through conference presentations and
publications in popular media—made accessible to the international community of
TC practitioners and researchers and to the general public.
International collaboration
The World Federation of Therapeutic Communities (WFTC) was founded in 1975,
followed by the establishment of the European Federation of Therapeutic Communities (EFTC) in 1981. The scientific branch of EFTC, the European Working Group
on Drugs Oriented Research (EWODOR) was established in 1983. Since that date,
EFTC and EWODOR have regularly organized conferences and symposia, which
were used as a forum for international exchange and scientific presentations about
recent developments in TCs and other residential treatment modalities. These international meetings provoked opportunities for the further scientific grounding of the
treatment model in De Kiem and other TCs (Broekaert, Vandevelde, et al. 2002).
History and development of TCs worldwide
TCs for addictions, also called drug-free, hierarchical, or concept TCs, are an international movement and are part of a long tradition of TCs. After Eric Broekaert was
appointed professor at Ghent University, much of his theoretical work was dedicated
to the study of the background and influences that have inspired TC treatment. The
research demonstrated that De Kiem and other European drug-free TCs belong to a
third generation of therapeutic communities (Broekaert, Vandevelde, Soyez, Yates,
& Slater, 2006).
Three generations of TCs
The first generation of therapeutic communities originated in the United Kingdom
during World War II. As a consequence of the atrocities of war, soldiers with psychological problems were cured at the Hollymoor Hospital in Northfield (Birmingham,
England) between 1942 and 1948 (Broekaert et al., 2000). The first Northfield experiment took place under the responsibility of John Rickman and Wilfred Bion. They
aimed at exploring group dynamics and leadership in group processes and decision
making in difficult circumstances. Soon, disciplinary problems arose as Rickman
and Bion underestimated the complexity of the interactions within the TC. As a consequence, the first Northfield experiment failed. Tom Main and Harold Bridger were
appointed for the second Northfield experiment. Bridger, a mathematics teacher,
was familiar with project learning and created social clubs that functioned as spaces
for growth and learning for the clinic as a whole. In 1946, Main described the hospital as a therapeutic environment, which can be regarded as the moment when the
concept of TC was first born. At about the same time, Maxwell Jones developed the
democratic TC. He challenged the hierarchic relations between doctors and nurses
in psychiatric hospitals and strived for consensus in decision making. To do so, the
social interactions between all parties involved had to be established, a painful process that was described by Jones as “social learning.” Jones also played an important
role in the introduction of TCs into the correctional system (Vandevelde, Broekaert,
Yates & Kooyman, 2004). It was also around the same time that the work of Jacob
Moreno on psychodrama and sociometry became influential (Moreno, 1934). In the
1920s, Moreno published his innovative ideas on group psychotherapy in prisons,
but—analogously to the rise of democratic therapeutic communities—it took until
the outbreak of the Second World War before his thoughts gained ground (Moreno,
The second generation of TCs can be traced back to Synanon, the cradle of
TCs for addictions (Broekaert et al., 2006). Charles “Chuck” Dederich, a welleducated and intelligent ex-alcoholic who sobered up through Alcoholics Anonymous, founded Synanon. He was well-aware of the work of the American neoromantic idealist philosopher Waldo Ralph Emerson, as well of Christian and Eastern
religions. The philosophy of Synanon was also closely linked with that of the hippie
movement, characterized by its alternative lifestyle and pursuit for community life,
love, and peace. In Synanon, a structured lifestyle was combined with inhibited free
conversations and emotional expression. The Synanon movement expanded quickly
and served as a model for the first American drug-free TCs, such as Daytop Village,
Phoenix House, and Odyssey House. However, these TCs split off from Synanon as
the latter demanded lifelong engagement and neglected reinsertion in society after
the treatment phase. Synanon and Dederich did not end well. Based on its affiliation
with the Alcoholics Anonymous-movement, Dederich proclaimed Synanon to be a
religion itself and this religion turned into a cult (Broekaert et al., 2000; Kaplan &
Broekaert, 2003). Dederich acted as a charismatic but paranoid leader and relapsed
into alcoholism. Synanon was dissolved in 1991 and Dederich died in 1997. Interviews with former Synanon members about this period showed their loyalty to the
alternative community life, but also demonstrated that ex-members took distance
from the crazy behavior of “the old man” (Goethals et al., 2011).
In a third wave, the American drug-free, hierarchical TC expanded all over
Europe through Phoenix House in London and Emiliehoeve in the Netherlands
(Broekaert et al., 2006). TCs were established in Belgium, Germany, Greece, Ireland, Italy, Norway, Spain, and Sweden. The American TC model had to be adapted
to the European culture. This implied that learning experiences were not primarily
seen as a method to change negative behavior, but rather as educational measures.
The harsh behavior modification techniques typical for the second generation of
American drug-free TCs were supplemented by a more humanist approach and
empathic understanding and dialogue, grounded in educational and social learning
theories (Broekaert et al., 2006). As opposed to the United States where ex-addicts
were in charge in most TCs, well-trained professionals from various backgrounds
such as psychiatrists, pedagogues, psychologists, and social workers shaped TC environments in Europe.
Application of the TC model in De Kiem
The influence of contextual therapy, psychoanalysis, and the antipsychiatric humanist movement was of great importance in European TCs. This was also the case in
De Kiem, where scientifically underpinned choices of adapted therapies and interventions were integrated in the pedagogical model of the TC. By using a broad
range of professional disciplines and backgrounds, it surpassed the borders of unocentric thinking and practice. Psychiatrists, psychologists, orthopedagogues (“Masters in Special Needs Education”), educators, and social workers worked together
to improve assessment processes and therapeutic/educational action planning
(Broekaert, 2006). From the start, ex-addicts (experts by experience) were engaged
as staff members and stimulated to become professionally trained educators.
Through its central position in Belgium and Europe, the TC model in De Kiem
was further influenced and also inspired other organizations. TCs were established
all over Belgium: in the Flemish region (De Sleutel, Katarsis), Walloon region (Choisis, Trempoline), Brussels capital area (De Spiegel, Solbosch), and even in the small
German-speaking part of the country (Les Hautes Fagnes). The regular exchange
between these facilities with different backgrounds, traditions, and languages stimulated cultural diversity in Belgian TCs. Also, staff members of De Kiem took prominent positions in the EFTC and EWODOR networks and participated actively in the
annual meetings of these organizations that attracted TC professionals and scholars
from all over Europe. This involvement promoted the search for new insights and
evidence-based practice in De Kiem, as well as learning from others’ experiences and
monitoring emerging theoretical and research findings that were presented by scholars from leading universities (Broekaert, Van der Straten, D’Oosterlinck, & Kaplan,
1999; Broekaert & Vanderplasschen, 2003).
Implementation of scientifically grounded instruments and methods
Improving psychiatric treatment in residential programs
Despite the long research tradition in American TCs, it was not until 1996 that a
joint research project was set up in European TCs. The “Biomed II-project” aimed
at Improving Psychiatric Treatment in Residential Programs (IPTRP) for newly
dependent groups through relapse prevention in a multicenter trial (Kaplan et al.,
1999). The study was funded by the European Commission and involved 33 residential programs (including De Kiem) in nine countries: Belgium, France, Greece,
Germany, Italy, Norway, Spain, Sweden, and the United Kingdom (Kaplan,
Broekaert & Morival, 2001). One of the study objectives was to implement standardized assessment instruments at various study sites to measure addiction severity,
psychopathology, childhood trauma, and social network characteristics (Broekaert,
Haack et al., 2002). The IPTRP-study evaluated the process of implementing standardized instruments in the participating treatment centers. The international
research team selected the European version of the Addiction Severity Index
(EuropASI) to cover addiction severity, Structured Clinical Interview for DSM-IV
Diagnosis (SCID-IV) to assess psychopathology, Childhood Trauma Questionnaire
(CTQ) to measure childhood trauma, Maastricht Social Network Analysis (MSNA)
to map social network characteristics, BioMAPS (Monitoring Area and Phase Systems) to cover treatment setting characteristics, and Video Addition Challenge Test
(VACT) to facilitate educational assessment and treatment planning.
Although the study resulted in 2,390 individual assessments, the implementation
process proved to be very difficult mostly because of the complex research design,
cultural differences, and translation difficulties and the demanding nature of implementing new instruments during staff ’s daily activities (Kaplan & Broekaert, 2003).
Still, the Biomed program showed to be a trendsetter for further research in European TCs and created a culture of inquiry, in particular in De Kiem. The project
contributed substantially to the internationalization of the European TC movement
by bringing together scholars from all over Europe, in close collaboration with the
EFTC. Most IPTRP-findings underscored the strong relationship between retention and treatment outcomes, which stimulated the integration of various methods and interventions to support retention in European TCs (e.g., motivational
enhancement, role of peers, and senior residents; Broekaert, Haack et al., 2002;
Broekaert, 2006; Kaplan et al., 2001).
Implementation of instruments and methods in De Kiem
Although not yet known at the time of the IPTRP study, there is scientific evidence
that the use of assessment instruments during the first months of treatment, accompanied by feedback on its findings, is associated with longer length of stay (retention)
in treatment (Raes, De Jong, De Bacquer, Broekaert, & De Maeseneer, 2011). Consequently, it was concluded that the implementation of instruments contributes indirectly to more favorable results. Presumably, this effect can be attributed to increased
attention for building up a positive therapeutic relation (Raes et al., 2011). Also,
the implementation of the VACT, a video script displaying the life story of an average resident that is shown to TC candidates during the first phase of treatment,
resulted in a finer probe for disclosing candidates’ life story and subsequent catharsis (Broekaert et al., 2001). It was learned not to use the VACT at the beginning of
the TC treatment process, when candidates have to write their life story in general
terms. Instead, it appeared beneficial to wait a few months, until residents had made
behavioral changes and were motivated internally. During the VACT, residents’ past
and former traumatic experiences are explored. As female residents reacted differently to the test and the script, an adapted video script was developed for women
(Broekaert & De Wilde, 2005; Broekaert & Soyez, 2010).
Based on a secondary analysis of the Biomed data, gender differences in
European TCs as well as gender sensitivity of the community as method approach
were explored (De Wilde, Broekaert, Segraeus & Rosseel, 2006). The study concluded that women in TCs had more severe psychiatric problems than men and
that traditional TCs were primarily male-oriented (De Wilde et al., 2004; De Wilde,
Broekaert, & Rosseel, 2006). As a consequence, several strategies were discussed to
enhance gender sensitivity in De Kiem, including separate women groups, women
days, and even the development of a separate TC for women was shortly considered (De Wilde, Broekaert, Segraeus, et al., 2006a). Ultimately, women groups were
installed, as well as closer attention for female and male therapeutic encounters and
a monthly women day for female residents from all TCs in the region.
Strengthening the evidence-base of the TC method
Given the need to legitimize the TC approach and the overall poor evidence-base for
the effectiveness of TCs, the management of De Kiem was always eager to participate
in studies that could improve or justify TC practice. In this section, several studies
are highlighted that introduced new practices or evaluated existing ones.
The welcome house phase
In 1997, De Kiem opened a welcome house to address drop-out in the early phases
of residential treatment and its detrimental impact on the group functioning. This
welcome house is situated outside the TC, offering an initial, residential program
to give TC aspirants the opportunity to accommodate to the TC philosophy and
principles during 4 to 8 weeks. Although welcome houses have a long tradition in
some countries (e.g., Italy, Belgium), their implementation has been poorly studied
and came only recently under the attention of the scientific community (Tompkins,
Neale, & Strang, 2017). Administrative data regarding treatment length in De Kiem
demonstrated that treatment retention and completion rates increased significantly
after the introduction of the welcome house period. Average retention rates rose
from 6 to 9 months and the number of program completers augmented from 20%
to 45–70% (Vandevelde, 2014). Anecdotal evidence shows that the welcome house
period offers unique opportunities to deal more flexibly with inclusion and exclusion
criteria for TC treatment (e.g., in case of relapse, time-out).
A mother and child service
Around the same period, a mother and child service (the Tipi) was established in De
Kiem, as an annex to the TC to address the underrepresentation and early drop-out
of women (Hughes et al., 1995; Sacks et al., 2004). By providing mothers the opportunity to follow the TC program without being separated from their children, the
number of women in the program increased as did completion rates. Mothers follow the TC program during the day and take care of their children at night and during weekends, supported by TC staff. Besides enhancing motivation and retention,
the program allows to (re)build the relationship with the child(ren) and to address
any developmental problems. Based on a small-scale qualitative study among 27
mothers who participated in the program for at least 2 months, it appeared that
the parent–child relation and overall quality of life of the mothers improved substantially (Vanderplasschen, Van Rompaye, Littera, & Vandevelde, 2015). Participating mothers deemed a supportive social network and educational support prerequisites for recovery and upbringing of the children after the residential treatment
Adapted encounter strategies
A quintessential element of the TC approach, is the encounter group method. Two
prototypical encounter groups in TC De Kiem were compared, one held in 1980 and
one in 2000, that were led by the same therapist (Broekaert, Vandevelde, Schuyten,
Erauw, & Bracke, 2004). Qualitative data-analysis methods were used to measure
the evolution of encounter groups and similar categories were applied to code group
participants’ and therapist’s behavior. It was found that the more recent encounters
(“new encounter group”) were characterized by more respect between participants
during confrontations. Also, more attention was paid to the person who was confronting rather than to the behavior of the one confronted. More negative emotions
were expressed in “new encounter groups” (as a release of hard feelings), while few
differences were observed in the attitudes of group participants.
Social network support
Following the ground-breaking study by Martien Kooyman (1993) on family
involvement in TCs in the Netherlands, pathways were explored to create opportunities for family members to participate in the program (e.g., visits and contact moments, parent groups). As part of a PhD study (Soyez, De Leon, Broekaert,
& Rosseel, 2006), a social network intervention was implemented using a quasiexperimental design in four Belgian TC programs (n = 207). The social network
intervention consisted of a video, participation at an induction day and a discussion session that aimed at enhancing motivation for treatment and retention. Hierarchical regression analyses showed that retention in the program was primarily
explained by client-perceived social support, treatment motivation and readiness
and significant others’ participation in the intervention (network involvement). It
was concluded that TC functioning and outcomes can be improved by involving the
social network and adding social network interventions to the program (Soyez, De
Leon, Rosseel, & Broekaert, 2006).
Outcome evaluation
In absence of outcome evaluation studies in Belgium, a follow-up study was set
up in TC De Kiem to measure the psychosocial situation of former residents 5 to
12 years after starting treatment. Data were collected using the European version
of the Addiction Severity Index (EuropASI) during three consecutive studies and
involved in total 135 residents that entered the program between 1997 and 2004.
Almost 70% of them (n = 92) participated in a follow-up interview, indicating a high
success rate (63%) among this self-selected sample (Soyez & Broekaert, 2009). Positive outcomes were associated with program completion (graduation) and length of
time spent in the program.
Treatment process determinants
To further explore the role of retention in TC outcomes, the influence of clients’ perceptions of TC treatment process elements was studied, as these are important determinants of program adherence and, eventually, outcomes (De Leon, 2000; Goethals,
Vanderplasschen, Vandevelde, & Broekaert, 2015). In total, 180 participants from
five residential TCs for addictions in Flanders (Belgium) were assessed 1 to 2 weeks
before entering the TC, and 1 (Time 1), 4 (Time 2), and 10 months (Time 3) after the
initial interview. Data collection included demographic and background variables,
motivation and readiness for treatment and the Dimensions of Change Instrument
(DCI), as a measure of treatment process (Orlando et al., 2006; Edelen et al., 2008).
It appeared that clients’ adherence to the community as method approach during
the first month of treatment relied strongly on their initial levels of motivation (i.e.,
suitability) and psychological well-being (Goethals, Vanderplasschen, Vandevelde,
& Broekaert, 2012). Differences in clients’ perceptions regarding self-change were
not associated with dynamic client factors and were only weakly related to client
background variables.
Publications in the TC journal
Finally, an important moment in strengthening the TC movement and its evidencebase in Europe was when the growing understanding between hierarchical and
democratic TCs cumulated in joint efforts to co-edit the TC Journal, currently
named Therapeutic Communities: The International Journal of Therapeutic Communities. Since 2005, a board member of the EFTC became a co-editor of this international peer-reviewed journal, which facilitated the publication of papers about
European drug-free TCs, and De Kiem in particular (Broekaert, Colpaert, Soyez,
Vanderplasschen, & Vandevelde, 2007; Broekaert, Vandevelde, & Briggs, 2011).
What kind of knowledge is needed in TCs?
Different knowledge paradigms
Based on available knowledge on TCs in the literature and findings from studies in
De Kiem, we discuss in this section paradigms of knowledge and evidence that is
needed to further advance TC research. The current era is characterized by a focus
on evidence-based practice (Miller, Sorensen, Selzer & Brigham, 2006). A fundamental question in this regard is how to define different paradigms of knowledge
and in which way these different strands contribute to evidence-based practice. The
classic paradigms used in education, health, and social sciences are also applicable
to substance abuse treatment, as illustrated by Broekaert and colleagues in the article “The human prerogative” (Broekaert, Autrique, Vanderplasschen, & Colpaert,
2010). These paradigms are labeled the existential-phenomenological, empiricalanalytical, and critical dialectic-materialistic approach. One could say that the first
one relates to interpretation and understanding by means of qualitative methods.
The second pertains to explanation and causality using quantitative methods. The
third one is linked to emancipation and empowerment, with no clear preference
for quantitative or qualitative methods. To integrate these three different strands,
Broekaert and colleagues (2010, p. 233) have referred to a fourth holistic paradigm:
“The integrative scientific point of view searches for the integration of diverse
types of interventions, as well as methodological approaches. It means that various
treatment modalities, paradigms of care and research methodologies can alternatively go together.” This approach relates well with different perspectives on knowledge/practice in youth care, as discerned by Van Yperen (2010): evidence-based (or
research-based), practice-based (or expert-based), consensus-based, value-based,
and client-based. These concepts refer to the importance of integrating various perspectives in treatment, education, and research, which has been exemplified in therapeutic communities for addictions (Broekaert et al., 2010).
Research methods in TCs
Many scholars who carried out research in therapeutic communities struggled
with methodological questions and concerns, not at least due to the dichotomy
between inside and outside researchers. Since the first scientific endeavors in TC
De Kiem, a schism was observed between large-scale (American) quantitative studies and smaller-scale (European) qualitative research (Broekaert, Vandevelde et al.,
2002). Although the added value of interpretative, qualitative data was never questioned, methodological issues regarding validity and reliability of the study design
remained. Answers were found in an intersubjective approach of qualitative research
(Broekaert, Moortgat, Soyez & Raes, 2009).
Systematic and narrative reviews can be regarded as accumulations of knowledge
on specific subjects. In 1999, an international team of scholars reviewed the state of
the art of TC research in Europe. The outcomes of TC research in several European
countries (Belgium, Germany, Italy, the Netherlands, Norway, Sweden, Switzerland,
and the United Kingdom) were analyzed critically and compared with the results of
American studies (Broekaert, Raes, et al., 1999). The findings showed a dearth of
well-documented studies from Europe, which lacked randomization and relied on
self-selection. A greater need for qualitative research was recommended, as the TC
is seen as an existentialist and humanist environment that is closely related to meaningful action and phenomenology: “While the reciprocal influence of the individual
and the environment can be reduced to quantitative indicators to some extent, a
qualitative record of the experience of the individual of the disorder and the recovery process is essential” (Broekaert, Raes, et al., 1999, p. 30).
Several systematic reviews have been published about the effectiveness of TCs for
addictions, usually focusing on longitudinal and controlled studies (Lees et al., 2004;
McCollister et al., 2003; Sacks & Sacks, 2010). Apart from the lack of studies from
Europe, it is striking that few studies were included in all of these reviews, which
can be partly explained by the different scope, objectives, selection criteria and analytical methods (Vanderplasschen et al., 2014). Despite several qualitative studies
on TC functioning, no narrative synthesis of qualitative studies was published yet.
An update of the outdated Cochrane meta-analysis on TCs (Smith et al., 2006) is
needed, because several outcome studies were published since that date.
Integration of quantitative and qualitative methods
Despite the dichotomy, it soon appeared that qualitative and quantitative approaches
could be combined methodologically, for example through the case-oriented
quantification approach (Kuckartz, 1997). This method is linked with WinMax/MaxQDA software package, which is based on the theoretical work of Weber
and Schutz. For the construction of typologies, however, Weber and Schutz developed their work from a slightly different theoretical perspective (Colins, Broekaert,
Vandevelde & Van Hove, 2008). This makes it hard to combine their work into an
integrated theory which underpins the WinMax approach, because it is difficult to
find a balance between an inter-subjective and rational, empirical understanding of
verstehen of phenomena. Still, text analyzing tools that imply possibilities of combining qualitative and (further) quantitative analyses have proven to offer relevant
opportunities for TC research.
Although randomized controlled trials are recognized as the gold standard for
research on treatment efficacy, random assignment of clients in TC research will
always be problematic for methodological, ethical, and practical reasons (Pearce &
Autrique, 2010). Randomization challenges the ethical principle of “free choice to
engage in treatment and research,” which is highly respected as self-selection is a
core principle in TCs (De Leon, 2010). Also, the selection of comparable treatment
conditions, inclusion of equivalent groups and substantial drop-out over lengthy
follow-up periods are serious threats to RCTs in TCs. Yet, TCs were forced to search
for appropriate answers, because the Cochrane Collaboration has long considered
random assignment to be the sole source of scientific evidence. In a first attempt
to prove TC effectiveness, the Oxford Science Group for Therapeutic Communities met at St. Hildas College in Oxford in 2008, under the leadership of Dr. R.
Haigh. The meeting included experts from democratic TCs and TCs for addictions
and prerequisites for starting randomized controlled research in TCs were discussed
(Pearce & Autrique, 2010). It resulted eventually in a pilot RCT in the Oxfordshire
Complex Needs Service, under supervision of Dr. Steve Pearce (Autrique, Pearce,
& Vanderplasschen, 2015). The RCT showed that treatment in a democratic therapeutic community (DTC) for people with personality disorders was as effective as
treatment as usual and crisis planning to reduce use of in patient services (Pearce
et al., 2017). However, outcomes regarding satisfaction with care and self- and other
directed aggression were signifcantly better in the DTC group, which led the authors
to the conclusion that DTC treatment is more effective than treatment as usual in
improving outcomes in persons with personality disorders.
Lessons learned and future research topics
Lessons learned
Based on several studies over the past 40 years in De Kiem, it appears that TCs have
been a natural lab for experiments and innovations and for implementation of new
ideas and interventions. The international TC movement is characterized by a constant search to improve effectiveness and integrate innovative approaches (De Leon,
2010). This case study clearly illustrates the crucial role of enthusiastic founders and
driving forces to implement and preserve the method. Eric Broekaert studied the TC
method abroad in some of the prototypical TCs and implemented and monitored
it in daily practice in De Kiem. The method was adopted and further spread by
his successors. Through his doctoral research, a culture of inquiry was introduced
from the start which would eventually result in a wealth of studies and publications
in peer-reviewed journals, based on research and practice in De Kiem. Staff members participated in the annual meetings of the World and European Federation of
Therapeutic Communities and in EWODOR conferences, which led to the discussion about and integration of innovative methods. As such, belief in the method
was combined with a search for evidence and De Kiem became a template for other
Belgian and European therapeutic communities (Vanderplasschen et al., in press).
Much of the initial research was dedicated to the history and origins of the drugfree TC, tracing it back to the first post-war therapeutic groups and environments
and characterizing it as an educational method (Broekaert et al., 2013). De Kiem
was identified as an example of the so-called third generation of TCs, integrating the
original American model and European influences, theories, and cultural practices
(Broekaert et al., 2006). A professional, multidisciplinary team is in charge of the TC
and includes several experts by experience. After the appointment of Eric Broekaert
as a university professor, De Kiem became an associated research partner, which
promoted the introduction of new insights and participation in numerous research
Participation in a large-scale European study on improving residential treatment
(Kaplan et al., 2001) introduced new instruments and methods and supported the
recurring conclusion that program retention in TCs is associated with improved
outcomes. Subsequently, various interventions and adaptations were implemented
in TC De Kiem to enhance motivation and retention. A welcome house phase
was introduced to facilitate accomodation to the TC program and principles and
improved drop-out rates substantially. Also, the implementation of a mother-child
program and introduction of gender-sensitive approaches contributed to increased
participation and retention of female drug abusers. The integration of a social
network intervention contributed indirectly to program retention, as TC residents experienced more social support and as their motivation and social network
involvement increased (Soyez et al., 2006). Moreover, the systematic implementation of diverse assessment instruments and use of interpretative, phenomenological
research methods ameliorated assessment and treatment procesess and led to more
individualized, tailored interventions, while respecting the community as method
Future research
One of the latest evolutions in addiction research is the focus on recovery, characterized by a search for persons’ strengths and capacities, meaningful social roles and
appropriate formal and informal support mechanisms (Slade, Amering, & Oades,
2008; Vandevelde et al., 2017). Recovery is described as “a deeply personal, unique
process of changing one’s attitudes, values, feelings, goals, skills, and roles. It is a way
of living a satisfying, hopeful, and contributing life, even with any limitations caused
by illness” (Anthony, 1993, p. 527). Although the term recovery is not unfamiliar
in TC environments, it was primarily defined as what is now called clinical recovery (absence of symptoms/abstinence). Still, concepts such as re-integration or even
personal and social integration are well-established. Personal integration refers to the
growth and development of the person through the therapeutic program, whereas
social integration in TCs is associated with the re-entry phase and refers to the process of leaving treatment and reinsertion in society (Zimmer-Höfler et al., 1985). It is
illustrative that the term recovery was only retrieved in one abstract of the proceedings of all EFTC, WFTC, and EWODOR conferences held between 1980 and 2015.
Consequently, increased attention for personal recovery in TC research is needed,
as this may shed an alternative light on TC outcomes (Vanderplasschen et al., 2013).
Also, the concept of quality of life has been poorly studied in TCs, although it is necessary to look beyond socially desirable outcomes such as abstinence, paid work, and
desistance (e.g., personal well-being, job satisfaction; De Maeyer, Vanderplasschen
& Broekaert, 2009; Broekaert et al., in press).
De Kiem has always been at the forefront to test new interventions and approaches
and to integrate these into the TC program, with great scrutiny to adhere to the original model. Studying TCs from a personal recovery perspective may open new directions for future research and puts it at the center of postmodern approaches, which
emphasize the importance of empowerment, inclusion, quality of life, and emancipation of citizens. From a postmodern research paradigm, there is no clear preference for qualitative or quantitative methods and the flexibility of the TC method and
concepts is acknowledged. Consequently, knowledge can be built on the alternation
of different paradigms and viewpoints (Broekaert et al., 2010). Advancing knowledge and science should not only take into account the historical dimension, but
also embrace present-day approaches that are part of the contemporary “zeitgeist.”
We are extremely grateful to our beloved friend and co-author Eric Broekaert, who wrote a preliminary draft of this paper, but passed away unexpectedly on September 26th, 2016 in Rome
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Change in
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TAP 31
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Implementing Change in Substance
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Recommended Citation
Center for Substance Abuse Treatment.
Implementing Change in Substance Abuse
Treatment Programs. Technical Assistance
Publication Series 31. HHS Publication No.
(SMA) 09-4377. Rockville, MD: Substance
Abuse and Mental Health Services
Administration, 2009.
Originating Office
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HHS Publication No. (SMA) 09-4377
Printed 2009
Chapter 1—Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Challenges of Implementing Change in Substance Abuse Treatment . . . . . . . . . . . . . . 1
Core Concepts Presented in TAP 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Models for Implementing Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Principles of Implementing Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Organization of TAP 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Chapter 2—Preplanning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
What Are the Best Practices/Programs?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
How Does Your Program Compare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
How Do TAU Outcomes Compare With EBP Outcomes? . . . . . . . . . . . . . . . . . . . . . . . 10
Is Your Program Ready for Change?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Is Change Realistically Feasible? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Chapter 3—Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Who Should Be at the Planning Table? Selecting the Change Team . . . . . . . . . . . . . . 19
Where Exactly Do You Want To Go? Defining Your Destination . . . . . . . . . . . . . . . . . 20
Are You Ready for the Trip? Revisiting the Organizational Assessment. . . . . . . . . . . 21
What Are the Change Targets? Setting the Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
What Is Your Route? Mapping the Implementation Plan . . . . . . . . . . . . . . . . . . . . . . . 26
Chapter 4—Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Are You There Yet? What To Expect Along the Way. . . . . . . . . . . . . . . . . . . . . . . . . . . 27
How Do You Navigate Roadblocks? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
You’re (Almost) There! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Chapter 5—Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Before You Begin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Estimating Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Planning the Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Collecting Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Analyzing Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Implementing Change in Substance Abuse Treatment Programs
Chapter 6—Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Sustainability Phases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Where’s the Money? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Appendix A—Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Appendix B—Implementation Theory Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Appendix C—Evaluation Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Appendix D—Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Appendix E—Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
2-1 Identifying EBPs Missing From a Hypothetical Program’s
Family-Based Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2-2 Comparing EBPs With a Hypothetical Program’s Practices. . . . . . . . . . . . . . . . . . 12
2-3 Sample Change Decision Tree. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3-1 Sample Measure and Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3-2 Change Tracking Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
5-1 Pros and Cons of Evaluation Approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5-2 Sample Evaluation Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
5-3 Comparison of Data Collection Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
6-1 Sample Budget Forecast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Chapter 1—Introduction
Technical Assistance Publication (TAP) 31:
Implementing Change in Substance Abuse
Treatment Programs offers guidance on how
to integrate evidence-based practices (EBPs)
for substance abuse treatment into clinical
practice. Informed by the realities of many
substance abuse treatment providers, it
suggests efficient solutions for implementing
change based on proven methods. Through a
practical step-by-step narrative, it explains
how to assess an organization’s capacity
to identify priorities, implement changes,
evaluate progress, and sustain effective
programs over the long run. This TAP
complements the best practices offered to
administrators in the Center for Substance
Abuse Treatment’s (CSAT’s) Treatment
Improvement Protocols (TIPs) and will be
of use for any treatment program or agency
implementing change or EBPs. The audience
is administrators attempting to integrate
EBPs into their programs.
Change is a reality for all substance abuse
treatment agencies and organizations.
Rates of substance abuse rise and fall,
substances of abuse emerge or are rediscov­
ered, science uncovers the mechanisms of
addictions, and researchers identify effective
interventions. Over the past two decades,
EBPs for substance abuse treatment have
shifted dramatically from 28-day, 12-Step­
based programs to individualized treatment
that addresses a client’s multiple needs
(Macmaster, Holleran, Chantus, & Kosty,
2005). Providers now implement increasingly
specialized interventions, including
pharmacotherapy, with fewer resources.
Challenges of Implementing
Change in Substance Abuse
For underresourced substance abuse
treatment organizations, attempts to
integrate EBPs are sometimes performed
piecemeal as resources allow. Compared
with other healthcare sectors, substance
abuse treatment is particularly slow in
adapting EBPs (Sloboda & Schildhaus,
Responding to the dynamic landscape
of substance abuse treatment is often
complicated by organizational dynamics.
The 2006 National Survey of Substance
Abuse Treatment Services found that
although the total number of substance
abuse treatment facilities remained virtually
the same between 2002 and 2006, there was
considerable turnover (Office of Applied
Studies, 2007). Each year, new programs
began and between 10 and 17 percent
of programs closed or stopped providing
substance abuse treatment services
altogether. Adding to the organizational
upheaval, substance abuse treatment
programs often lack sufficient staff to meet
client needs. For many organizations, staff
turnover is a constant. CSAT (2003) reports
that staff turnover ranges from 19 to
33 percent per year.
Substance abuse treatment organizations
must adapt to factors imposed by the healthcare system. Changes in managed care and
reimbursement affect the entire substance
Implementing Change in Substance Abuse Treatment Programs
abuse treatment system and are keenly felt
at the provider level. Healthcare systems
expand and contract, compelling organiza­
tions to adopt new policies and procedures.
Cuts in managed care reimbursement for
substance abuse programs render substance
abuse treatment facilities increasingly
dependent on public funding (Macmaster et
al., 2005, p. 70). New regulations are imple­
mented, revised, and repealed, often imposing
additional administrative burdens.
improvement is essential to the long-term
stability of their organization.
Why Implement EBPs?
Implementing EBPs can help overcome the
financial and organizational challenges that
make change so difficult. Implementing EBPs
Improve client outcomes. EBPs are
interventions shown to be effective with
specific client populations. Adopting
practices with a proven record improves
chances of helping people within these
populations recover from the devastating
consequences of substance use disorders.
Increase access to effective
treatment. Implementing interventions
and programs with proven effectiveness
gives an organization the greatest chance
of helping the most people.
Engage staff. Implementing change
involves the entire organization. Involving
staff and key stakeholders in the process
can improve buy-in, enhance motivation,
and ultimately reduce turnover. Improved
client outcomes can encourage staff
members and make them feel better about
their work.
Improve operating margins. EBPs
can reduce treatment costs while
improving outcomes (Schneider, Peterson,
Vaughn, & Mooss, 2006). More effective
interventions and processes can reduce
relapse and recidivism, requiring fewer
treatment cycles. Proven, targeted
treatments also may enable programs to
eliminate less effective program elements
and increase volume, thereby improving
the bottom line.
Save time. EBPs can streamline
treatment, reduce duplication of
services and strategies, and increase
staff productivity. If planned well,
implementation efforts can foster efficient
tracking of clients and outcomes, setting
Transferring “knowledge to practice” in the real
world can be viewed as adding even greater
pressure to do more with less.
—Simpson, 2002, p.172
Pressures To Implement Change
Adding to the organizational and systemwide
strain imposed on them, substance abuse
treatment programs face increasing pres­
sure from funding and regulatory agencies,
insurers, researchers, consumers, and family
members to implement EBPs. For substance
abuse treatment organizations, adopting
EBPs poses unique challenges. For example,
substance abuse treatment programs typi­
cally serve diverse populations with complex
problems that do not easily fit criteria for
best programs and practices (Iowa Practice
Improvement Collaborative Project, 2003).
Moreover, most substance abuse treatment
programs use a credentialed practitioner
model that gives individual practitioners the
freedom to adopt eclectic approaches. Super­
vision is often administrative, with limited
feedback on clinical competence, and staff
evaluations are not generally tied to the use
of EBPs. Finally, funding is often based on
reimbursable treatment hours, leaving lim­
ited resources for considering and implement­
ing more effective practices (Fixsen, Naoom,
Blase, Friedman, & Wallace, 2005).
Despite these challenges, many agency
administrators are committed to making
improvements in their service delivery
systems. They know that continuous
Chapter 1—Introduction
the groundwork for future change and
Transform organizations from
reactive to responsive. Many
organizations are plagued by crises
that might have been prevented with
thoughtful planning. Through the
process of planning and implementing
change, some organizations develop
the infrastructure to readily identify
and address problems and implement
Provide justification for funding.
Systematic data collection and the
evaluation of outcomes are parts of the
change process. Evaluation provides
valuable information for grant and
accreditation applications and documents
outcomes to sell the program. Evaluation
data also can be used to justify a shift
in funding to practices that have proven
Core Concepts Presented in
TAP 31
Implementing change in substance abuse
treatment programs is guided by a number
of core concepts. Although precise definitions
differ, the following terms are used through­
out TAP 31.
Evidence-based practice (or best practice). Activity that is based on the best
available research in the context of patient
characteristics, culture, and preferences
(Institute of Medicine, 2001, p. 147). Research
consistently shows that EBPs have positive
outcomes with similar techniques and simi­
lar populations (National Implementation
Research Network, 2007). The Substance
Abuse and Mental Health Services Admin­
istration’s (SAMHSA’s) National Registry
of Evidence-based Programs and Practices
(NREPP, 2007) defines EBPs as:
Approaches to prevention or treatment
that are validated by some form of docu­
mented scientific evidence. What counts
as “evidence” varies. Evidence often is
defined as findings established through
scientific research, such as controlled
clinical studies, but other methods of
establishing evidence are considered valid
as well. Evidence-based practice stands in
contrast to approaches that are based on
tradition, convention, belief, or anecdotal
Distinctions can be made among EBPs, clini­
cal practice guidelines, and clinical pathways.
Generally, EBPs are established through
multiple randomized clinical trials that dem­
onstrate positive outcomes for a particular
intervention or practice in a number of set­
tings. Clinical practice guidelines are based
on current research findings and recommen­
dations by consensus panels composed of
experts in the field. They are general guide­
lines to help clinicians make better treatment
decisions (Iowa Practice Improvement Collab­
orative Project, 2003). Likewise, clinical path­
ways are suggested courses of action based
on specific clinical scenarios. Despite these
differences, EBPs, clinical practice guidelines,
and clinical pathways are all intended to
translate research into practice and improve
the effectiveness of treatment. TAP 31 uses
EBPs broadly to refer to research-based prac­
tices or guidelines intended to improve sub­
stance abuse treatment outcomes.
Evidence-based program (or best program). A set of practices embedded within
the larger service delivery structure and
involving multiple best practices. Evidencebased programs incorporate best practices
while maintaining the goals of the systems
in which the services are delivered (National
Implementation Research Network, 2007).
That is, an evidence-based program uses
many EBPs.
Diffusion (sometimes called technology
transfer or dissemination). The process by
which results (best practices) are dispersed
to the field. It includes efforts to educate
or inform, such as trainings, as well as dis­
seminating documents for provider use (such
as TIPs). Diffusion is not implementation;
Implementing Change in Substance Abuse Treatment Programs
rather, it is the process through which policymakers, clinicians, administrators, and
others are made aware of best practices.
Implementation. The process of putting
best practices in place. It can be a series
of discrete steps, or it can be a single event.
It can be ongoing, or it can have a limited
duration. Implementation usually involves
multiple people, systems, and processes.
Fidelity. The degree to which the clinician,
substance abuse treatment organization, pro­
gram, or administrator adheres to established
guidelines, policies, or procedures for best
practices. Generally, higher fidelity results
in better outcomes (Gotham, 2004). In this
TAP, fidelity refers to the degree to which the
EBPs outlined in a TIP are adhered to by the
target audience.
Reinvention. The process through which a
best practice is modified to fit the individual
program. Reinvention is sometimes neces­
sary, and it can be positive if it demonstrates
improved outcomes. For example, an 8-week
program can be cut to 6 weeks to fit the typi­
cal stay in a residential treatment program.
However, reinvention can be negative if it
leads to worse outcomes (Gotham, 2004).
Purveyor. An individual or group of individ­
uals that initiates and monitors change, such
as an administrator or clinical supervisor or a
group with a specific goal.
Change agents. Individuals in the organiza­
tion who promote change by using a shared
value system, institutional memory, or a
particular skill set; individuals who influence
Organizational change. An alteration in
the culture, customs, values, practices, or pro­
tocols of an organization or agency directed
at improving the organization’s readiness for
change and making the organization more
amenable to implementing EBPs.
No single conceptual model of change can
adequately be applied to all real-world sce­
narios. However, theories of diffusion, inno­
vation, or organizational change can provide
useful ways to conceptualize the change
process. The process through which research
makes its way into clinical practice has been
well described in the literature.
Online Resources
In The Change Book: A Blueprint for Technology
Transfer, the Addiction Technology Transfer
Center provides a step-based approach to
implementation. It is available online at http://
TAP 21-A: Competencies for Substance Abuse
Treatment Clinical Supervisors provides an
overview of implementing change in supervisory
practices. The document is available online
at http://ncadistore.samhsa.gov/catalog/
Implementation Research: A Synthesis of the
Literature is available online at http://nirn.fmhi.
SAMHSA developed NREPP—a searchable online
database of mental health and substance abuse
interventions that have been reviewed and rated
by independent reviewers. To search NREPP, go
to http://nrepp.samhsa.gov/index.htm.
The Network for the Improvement of Addiction
Treatment (NIATx), a national initiative sponsored
by the Robert Wood Johnson Foundation’s Paths
to Recovery program and CSAT’s Strengthening
Treatment Access and Retention program, offers
tools and case studies specifically for substance
abuse and mental health agencies seeking to
improve outcomes. For more information, go to
Generally, models are replications of processes or systems, and theories are abstract speculations. TAP 31 uses the
two interchangeably.
Models for Implementing
Chapter 1—Introduction
Once researchers determine that a particular
intervention, or combination of interventions,
works better than treatment as usual (TAU)
in specific populations, information about
these EBPs must be distributed to the field
through a variety of venues. Appendix B
provides a list of resource publications for
interested readers.
Diffusion of Innovations Theories
Rogers (2003) developed theories to explain
how innovations become reality. After
examining the mechanisms through which
innovations (e.g., best practices) become
standard practices, Rogers identified five
stages in the adoption of new practices:
1. Knowledge of the best practice.
Clinicians and administrators acquire
knowledge through attendance at
conferences and training seminars and
by reading TIPs and journals.
2. Persuasion of its value. A change agent
or purveyor convinces key people of the
importance of changing the approach.
3. Decision to adopt the innovation.
When general agreement is reached, the
decision is made to implement the new
4. Implementation of the practice. Best
practices are put into effect.
5. Confirmation to continue or reject
the process. Postimplementation
assessment leads to embracing (institu­
tionalizing) the practice or rejecting it.
In Rogers’ (2003) model, individuals play one
of several roles in responding to change:
Innovators—the risk takers
Early adapters—leaders
Early majority—deliberate
Late majority—traditionalists, skeptics
Laggards—those fearful of change,
unaware of trends.
Although Rogers’ model has been widely
embraced, it imposes limitations on substance
abuse treatment organizations attempting
to implement best practices. Rogers’ model
assumes that change is linear, following a
natural progression from awareness to adop­
tion (Gotham, 2004). For substance abuse
treatment organizations, changes are rarely
so clear-cut. Information is continually fed
into the process. Old ideas and systems can
be revisited and resurrected. Innovations
must fit regulatory and financial realities and
the existing organizational culture. Moreover,
Rogers’ model emphasizes the individuals
who make concrete decisions to implement
change. Although individuals may play key
roles in implementing change, organiza­
tions and systems also play important roles.
Finally, Rogers’ model fails to account for
education, training, supervision, and compe­
tency training required to sustain change.
Transtheoretical Models
Transtheoretical models stress the
importance of the organization’s readiness
to change and the targeted strategies to
improve readiness. These models place
the organization—its culture, structure,
and norms—central to the change process.
Hence, any attempts to implement best
practices must factor in the organizational
context. Transtheoretical models rest on
two key questions: Is the organization ready
for change? If not, what organizational
changes are needed to prepare it for
change? Prochaska and DiClemente (1983)
adapted the “stages of change” model for
individual change to describe the process of
organizational change. Organizations move
through five stages in the change process:
1. Precontemplation
2. Contemplation
Implementing Change in Substance Abuse Treatment Programs
3. Preparation
4. Action
5. Maintenance.
Although organizations consistently complete
each step, change is not necessarily a linear
To reduce the wait time between a client’s
first request for service and the first
treatment session
To reduce client no-shows
Implementation Models
To increase treatment centers’ admissions
Recognition of the distinctions between dis­
semination and adoption has increased. Dis­
semination and training sow the seeds for
change. Germination requires thoughtful
planning and sustained effort. The literature
strongly suggests that without specific strate­
gies to implement change, EBPs are unlikely
to find their way into clinical practice (Fixsen
et al., 2005). Fixsen and colleagues main­
tain that the implementation component is
precisely what has been missing in change
models and in resource allocation. Compared
with the resources allocated for identifying
best practices and disseminating research
results to the field, few resources are pro­
vided to show programs how to implement
effective practices. In fact, implementation is
the least researched component of the process
whereby research makes its way into practice
(Gotham, 2004).
To increase the treatment continuation
rate between the first and the fourth
treatment sessions.
Fixsen and colleagues (2005) maintain that
an implementation model without a clear
plan for change will not work. Basing their
opinion on a review of the literature, they
suggest that successful implementation is
possible only through simultaneous interven­
tions at practitioner, organization, systemof-care, Federal, State, county, and local
levels. Fixsen and others have pointed out
that implementation is not an event but a
mission-oriented process involving multiple
decisions, actions, and corrections. As Phillips
and Allred (2006, p. 172) assert, implementa­
tion of best practices is “a form of propagation
… similar to grafting.”
NIATx (https://www.niatx.net) promotes a
somewhat different implementation model.
It focuses on organizational change and on
small, manageable change measures that
promote financial sustainability and lead to
tangible results. NIATx has four aims:
According to the NIATx model, the essential
ingredients for successful process improve­
ment are:
Understand and involve the
customer. The “customer” is defined
broadly as clients, families and
friends, referral sources, payers, and
the community. Treatment providers
should ask clients about what needs
improvement and seek their advice on
how to improve services.
Fix the key problems. Focusing on
the problems that worry the executive
director helps garner support from the
organization’s leaders and ensure success.
Pick a powerful change leader. Those
in charge of organizational change must
have authority, the respect of their
colleagues, and sufficient time to devote to
the initiative.
Get ideas from outside the
organization or field. Other
organizations or even fields, such as
the hospitality industry, can offer fresh
Use rapid-cycle testing to establish
effective changes. The idea is to take
one small change at a time and see how it
works. After making the change, the team
evaluates the results, modifies the change
if necessary, tests it again, and repeats
the process until the change is good
enough to be made permanent.
Chapter 1—Introduction
The NIATx improvement model has five
Complete a walk-through to understand
customer needs
Pick a change goal
Identify a simple data point (or points)
that will help you determine whether you
reached your goal
Select and rapidly test relevant changes
one at a time
Sustain the gain.
For more information, see NIATx’s Resource
Guide to Process Improvement at https://
Principles of Implementing
Several principles guide TAP 31. All are
directly analogous to principles of substance
abuse treatment.
There is no single model for or approach
to implementing a program of organizational change. A preconception about how
change should occur or inflexibility during
the change process is counterproductive if not
fatal to meeting a program’s change goals.
Constant vigilance and in-course corrections
are needed. Corrections should be made in
consultation with the stakeholders who devel­
oped the original change plan. TAP 31 pro­
vides logical steps to implementing change.
The document is not intended to be rigidly
prescriptive; rather, it suggests how to go
about the change process, with references to
other resources to fill in the gaps. Programs
will need to modify the process to succeed in
changing or adapting.
The change program should be individualized to accommodate the specific
needs, goals, culture, and readiness to
change of an organization. For example,
The Implementation Headset
Dissemination and implementation are not the
same things. Fixsen and colleagues (2005, p. 4)
coined the phrase “implementation headset”
to encourage a different kind of thinking about
implementation. They postulate that, too often,
researchers, policymakers, administrators, and
managers assume that distributing information
about best practices to the field is sufficient.
Doing more or better research on a program or
practice itself does not lead to a more successful implementation. Training providers in how to
use a technique is not the same as incorporating
proven interventions into clinical practice. Implementation is an entirely different enterprise,
requiring an entirely different approach.
a suggested best practice may be to screen
all clients for infectious disease. Limited
resources may make this impossible. An
alternative would be to screen for HIV and
hepatitis and refer clients to a clinic offering
screening for other infectious diseases.
Change is not a linear process. Although
TAP 31 outlines a step-by-step approach,
sometimes it may be necessary to backtrack.
Perhaps early evaluation results reveal that
the new approach is not working. It may be
necessary to revisit the planning phase to
adjust the plan. Or it may become clear at a
later stage that the new program is not sus­
tainable when funding levels decrease, and
adjustments will be necessary.
Change is ongoing. Change is not a discrete
event. It is a process that requires careful
planning, coordination, cooperation, evalu­
ation, and followup. At least in the first few
years after the implementation of an organi­
zational change plan, continuing care of the
organization’s new accomplishments is criti­
cal to their long-term survival.
The ultimate goal is to create changes
that can be sustained over time. Even­
tually, the changes will become a regular
feature of the program’s operation through
a process called institutionalization. Insti­
tutionalization has occurred when the “new
practices” introduced have become the
Implementing Change in Substance Abuse Treatment Programs
“everyday practices” of the agency. Even after
institutionalization occurs, however, a com­
mitment to continuous quality improvement
ensures the program’s ability to respond to
future changes in the needs of the client
population and community.
Organization of TAP 31
The remaining chapters of TAP 31 suggest a
step or stage approach in which one compo­
nent logically follows another.
Chapter 2—Preplanning. At this stage,
decisionmakers determine whether best prac­
tices are worth implementing. The chapter
suggests practical ways to compare best prac­
tices with TAU, evaluate outcomes, and real­
istically assess whether change is possible or
Chapter 3—Planning. Implementation
requires forethought and planning. This
chapter suggests factors that should be con­
sidered in planning for implementation. It
recommends strategies to involve stakehold­
ers, anticipate problems, and align the orga­
nization with the impending changes.
Chapter 4—Implementation. With proper
planning, implementation is a matter of
following the established course. This chapter
suggests ways to execute plans, monitor
progress, and make adjustments, if
Chapter 5—Evaluation. Much of the work
for this step is done in the planning and
implementation stages. Evaluation is the
process of appraising or measuring outcomes,
comparing outcomes with baseline measures,
and determining what, if any, adjustments
need to be made.
Chapter 6—Sustainability. The best
programs and practices will be of little use
without a plan to sustain them over time.
This chapter introduces strategies to garner
the financial, political, and systemic support
to make the progress permanent.
Although there is a logical flow to the steps,
each stage depends on subsequent stages.
Evaluation components should be built into
the planning stage to establish the baseline
and assess what the change process should
address. Sustainability may be a large factor
in deciding whether to move forward with the
change plan and should be considered along
with other factors in the preplanning stage.
Chapter 2—Preplanning
Hypothetical Scenario
You are an administrator at a small intensive outpatient substance abuse treatment
program. Twenty percent of the funding for your organization comes from a block grant.
To qualify for renewed funding, the grantee must demonstrate that activities or projects
that are funded by monies used for substance abuse and mental health treatment include
an evidence-based component for family members. Your organization generally follows
evidence-based practices (EBPs) but does not currently offer comprehensive family
services. Clients in need of intensive family therapy are referred to a community health
facility, but there is no coordination of care between your facility and family therapy. You
are exploring the feasibility of adding an evidence-based family component.
An organization facing this scenario is in the
preplanning stage of implementing change.
At this juncture, no decision has been made
to commit to change. Rather, the program is
in the exploratory phase in which you ask key
What are the current practices?
How do outcomes from best practices
compare with outcomes from treatment as
usual (TAU)?
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