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CORK Bibliography: Clinicians

99 citations. January 2009 to present

Prepared: December 2011

Abdon JG; Wallin E; Andreasson S. The "Clubs against Drugs" program in Stockholm, Sweden: Two cross-sectional surveys examining drug use among staff at licensed premises. Substance Abuse, Treatment, Prevention and Policy 6: article 2, 2011. (38 refs.)

Background: The objective of this study is to examine self-reported drug use among staff at licensed premises, types of drugs used, attitudes towards drugs, and observed drug use among guests. Results are presented from two measurement points (in 2001 and 2007/08). This study was carried out within the framework of the "Clubs against Drugs" program, which is a community-based multi-component intervention targeting licensed premises in Stockholm, Sweden. Methods: Two cross-sectional surveys were conducted, the first in 2001 and the second in 2007/08. Staff at licensed premises attending server training were asked to participate in the anonymous survey. A survey was administered in a classroom setting and consisted of four sections: 1) demographics, 2) respondents' own drug use experience, 3) respondents' attitudes towards drug use, and 4) observed drug use among guests at licensed premises. Results: Data were collected from 446 staff in 2001 and 677 staff in 2007/08. The four most commonly used drugs among staff were cannabis, cocaine, amphetamine, and ecstasy. The highest rates of drug use were reported by staff in the two youngest age groups, i.e., those younger than 25 and those between the ages of 25 and 29. In 2007/08 staff reported significantly lower rates of drug use than staff in 2001. Last year drug use for the sample in 2007/08 was 19% compared to 27% for the 2001 sample. While drug-using staff compared to non drug-using staff reported more observations of drug use among guests, they were less inclined to intervene. Overall, staff reported restrictive attitudes towards drugs. Conclusions: The prevalence of life-time and last year drug use among staff at licensed premises is high compared to the general population in Sweden. Lower rates of self-reported drug use among staff were reported in 2007/08. The results of this study highlight that staff at licensed premises represent an important target population in club drug prevention programs.

Abraham AJ; Rieckmann T; McNulty T; Kovas AE; Roman PM. Counselor attitudes toward the use of naltrexone in substance abuse treatment: A multi-level modeling approach. Addictive Behaviors 36(6, special issue): 576- 583, 2011. (43 refs.)

Alcohol use disorders (AUDs) continue to be one of the most pervasive and costly of the substance use disorders (SUDs). Despite evidence of clinical effectiveness, adoption of medications for the treatment of AUDs is suboptimal. Low rates of AUD medication adoption have been explained by characteristics of both treatment organizations and individual counselor's attitudes and behaviors. However, few studies have simultaneously examined the impact of organizational-level and counselor-level characteristics on counselor perceptions of EBPs. To address this gap in the literature, we use data from a national sample of 1178 counselors employed in 209 privately funded treatment organizations to examine the effects of organizational and individual counselor characteristics on counselor attitudes toward tablet and injectable naltrexone. Results of hierarchical linear modeling (HLM) show that organizational characteristics (use of tablet/injectable naltrexone in the program. 12-step orientation) were associated with counselor perceptions of naltrexone. Net of organizational characteristics, several counselor level characteristics were associated with attitudes toward tablet and injectable naltrexone including gender, tenure in the field, recovery status, percentage of AUD patients, and receipt of medication-specific training. These findings reveal that counselor receptiveness toward naltrexone is shaped in part by the organizational context in which counselors are embedded.

Adams PJ; Warren H. Responding to the risks associated with the relapse of recovering staff members within addiction services. Substance Use & Misuse 45(6): 951-967, 2009. (20 refs.)

Practitioners working within addiction services who are recovering from their own addiction issues contribute positively to the strength of service interventions, but their recovery also poses risks, particularly those associated with the possibility of relapse. Little has been published on this issue despite its significant impact on the relapsing practitioners, their clients and colleagues, and the services themselves. This "point-of-view" article divides the various impacts of a practitioner's relapse into four phases and examines how services might develop early and late response strategies. It argues that formal monitoring processes can assist in both preventing and responding to the harms associated with these relapses.

Ashcraft RGP; Foster SL; Lowery AE; Henggeler SW; Chapman JE; Rowland MD. Measuring practitioner attitudes toward evidence-based treatments: A validation study. Journal of Child & Adolescent Substance Abuse 20(2): 166-183, 2011. (23 refs.)

A better understanding of clinicians' attitudes toward evidence-based treatments (EBT) will presumably enhance the transfer of EBTs for substance-abusing adolescents from research to clinical application. The reliability and validity of two measures of therapist attitudes toward EBT were examined: the Evidence-Based Practice Attitude Scale (Aarons, 2004), and Attitudes Toward Psychotherapy Treatment Manuals Scale (Addis Krasnow, 2000). Participants included 543 public sector, master's-level mental health and substance abuse therapists who treat adolescents. Factor analyses generally corroborated factor structures of the instruments found previously. Beliefs that EBTs negatively affect treatment process were associated with relatively low openness to new treatments and with beliefs that EBTs do not produce positive outcomes.

Ashton M; Lawn S; Hosking JR. Mental health workers' views on addressing tobacco use. Australian and New Zealand Journal of Psychiatry 44(9): 846-851, 2010. (24 refs.)

Objective: The aims of this study were to assess mental health workers' attitudes to addressing tobacco dependence with patients, to identify barriers that may prevent people with mental illness from receiving support, and determine workers' recommendations for tobacco policy and practice change. Method: Questionnaires were sent to government and non-government mental health services in Adelaide, South Australia. The questionnaires asked workers to rate on a Likert rating scale their attitudes to addressing tobacco use with patients and to respond to qualitative questions about managing tobacco use within mental health services. Quantitative data were analysed using SPSS version 15.0 and qualitative data was coded by three researchers into categories or themes and then analysed. Results: Questionnaires (324) were received from staff across 45 organizations providing clinical and psychosocial services. More than two thirds of the participants felt it was important for mental health services to be involved in assisting patients to quit smoking; however, only 26% said they raised the issue of tobacco use with patients, often or as part of the assessment. Respondents on average felt approximately one third of their patients could quit or reduce tobacco use if they received nicotine replacement therapy, information and support. Most workers suggested changes to policy and practice within mental health services including smoke free areas and the provision of information and support. Discussion: The rate of tobacco use amongst people with mental illness is still very high with serious social and health consequences. Mental health workers are uniquely placed to assist patients to quit or reduce tobacco use. This study has shown many workers believe that it is important to address tobacco use with their patients as part of routine care and that mental health services should implement significant tobacco policy and practice change.

Back S; Waldrop A; Brady K. Treatment challenges associated with comorbid substance use and posttraumatic stress disorder: Clinicians' perspectives. American Journal on Addictions 18(1): 15-20, 2009. (35 refs.)

A significant proportion of individuals with substance use disorders (SUDs) meet criteria for comorbid posttraumatic stress disorder (PTSD). This comorbidity confers a more complicated clinical presentation that carries with it formidable treatment challenges for practitioners. The current study examined sources of difficulty and gratification among clinicians (N = 423) from four national organizations who completed an anonymous questionnaire. As expected, the findings revealed that comorbid SUD/PTSD was rated as significantly more difficult to treat than either disorder alone. The most common challenges associated with treating SUD/PTSD patients included knowing how to best prioritize and integrate treatment components, patient self-destructiveness and severe symptomatology, and helping patients abstain from substance use. The findings increase understanding of SUD/PTSD treatment challenges, and may be useful for enhancing therapist training programs, supervision effectiveness, and designing optimal SUD/PTSD interventions.

Baxter S; Everson-Hock E; Messina J; Guillaume L; Burrows J; Goyder E. Factors relating to the uptake of interventions for smoking cessation among pregnant women: A systematic review and qualitative synthesis. (review). Nicotine & Tobacco Research 12(7): 685-694, 2010. (49 refs.)

The review had the aim of investigating factors enabling or discouraging the uptake of smoking cessation services by pregnant women smokers. The literature was searched for papers relating to the delivery of services to pregnant or recently pregnant women who smoke. No restrictions were placed on study design. A qualitative synthesis strategy was adopted to analyze the included papers. Analysis and synthesis of the 23 included papers suggested 10 aspects of service delivery that may have an influence on the uptake of interventions. These were whether or not the subject of smoking is broached by a health professional, the content of advice and information provided, the manner of communication, having service protocols, follow-up discussion, staff confidence in their skills, the impact of time and resource constraints, staff perceptions of ineffectiveness, differences between professionals, and obstacles to accessing interventions. The findings suggest variation in practice between services and different professional groups, in particular regarding the recommendation of quitting smoking versus cutting down but also in regard to procedural aspects, such as recording status and repeat advice giving. These differences offer the potential for a pregnant woman to receive contradicting advice. The review suggests a need for greater training in this area and the greater use of protocols, with evidence of a perception of ineffectiveness/pessimism toward intervention among some service providers.

Beidas RS; Koerner K; Weingardt KR; Kendall PC. Training research: Practical recommendations for maximum impact. Administration and Policy in Mental Health and Mental Health Services Research 38(4, special issue): 223-237, 2011. (108 refs.)

This review offers practical recommendations regarding research on training in evidence-based practices for mental health and substance abuse treatment. When designing training research, we recommend: (a) aligning with the larger dissemination and implementation literature to consider contextual variables and clearly defining terminology, (b) critically examining the implicit assumptions underlying the stage model of psychotherapy development, (c) incorporating research methods from other disciplines that embrace the principles of formative evaluation and iterative review, and (d) thinking about how technology can be used to take training to scale throughout all stages of a training research project. An example demonstrates the implementation of these recommendations.

Berends L. The emergence of a specialist role in rural alcohol and drug service delivery: Lessons from a review in rural Victoria, Australia. Drugs: Education, Prevention and Policy 17(5): 603-617, 2010. (23 refs.)

Aim: Perspectives on rural alcohol and other drug (AOD) service provision were explored. Methods: A mixed methods approach included a document review, service monitoring data, regional group fora with AOD and other health providers (109), semi-structured interviews with stakeholders from health, policy and research (53), and interviews with rural AOD services users (21). Findings: Alcohol is the main drug used by people in rural Victoria, followed by cannabis and then heroin. Services are allocated within a unit cost funding model and distributed on a regional or statewide basis. AOD treatment is dominated by outpatient therapy, outreach and rural withdrawal. Pharmacotherapy and residential rehabilitation are in short supply. Distance, stigma, and confidentiality concerns are barriers to treatment. Recruiting and retaining workers is difficult. The system continues to develop; secondary consultations and networking strategies increase capacity in other care systems. Hospital involvement in AOD treatment varies according to other health demands. Conclusions: Many aspects of the rural AOD service provider's role enhance service delivery by extending reach and capacity. This occurs through AOD models, such as outreach, as well as strategies for working with other systems that include networking and secondary consultation. While there is task diffusion beyond traditional understandings of AOD treatment, the service delivery role may be understood as specialist in its own right. Recognition of this role as specialist may support staff recruitment and retention, while building potential for career pathways.

Bonar EE; Rosenberg H. Substance abuse professionals' attitudes regarding harm reduction versus traditional interventions for injecting drug users. Addiction Research & Theory 18(6): 692-707, 2010. (22 refs.)

Investigations of attitudes regarding harm reduction have usually assessed the acceptance of specific interventions, but investigators have rarely compared the ratings of harm reduction interventions to the ratings of traditional interventions or tested whether the perceived value of harm reduction interventions varies as a function of client characteristics. Therefore, using a vignette describing an injecting drug user, we tested whether clinical administrators of substance abuse treatment agencies and licensed chemical dependency counselors rated the beneficence (on a 7-point scale from "Extremely Harmful" to "Extremely Beneficial") of injection-related harm reduction interventions (e. g., cleaning needles with bleach, muscling, non-injecting routes of administration) differently from the beneficence of traditional treatment interventions (e. g., self-help group, individual and group counseling), and whether client gender and human immunodeficiency virus (HIV) status impacted such ratings. In Study One, a set of traditional interventions was rated as more beneficial than a set of harm reduction interventions. Study Two showed that a subset of harm reduction interventions designed to prevent transmission of blood-borne diseases was seen as more beneficial than a subset designed to prevent overdose fatalities. Clinical administrators rated harm reduction as more beneficial for HIV-negative clients than for those whose HIV status was described as unknown (Study One), but there was no impact of HIV status on perceived beneficence of harm reduction among licensed chemical dependency counselors (Study Two). Gender of the vignette client did not influence the beneficence ratings in either sample.

Bonevski B; Bryant J; Paul C. Encouraging smoking cessation among disadvantaged groups: A qualitative study of the financial aspects of cessation. Drug and Alcohol Review 30(4): 411-418, 2011. (36 refs.)

Introduction and Aims. This study aimed to explore perceptions about financial aspects of smoking cessation among a group of disadvantaged welfare agency clients and their carers. Design and Methods. Qualitative focus groups and in-depth interviews were supplemented with participant exit surveys about preferred smoking cessation strategies. Each discussion was audiotaped, transcribed and analysed using a thematic analysis. The setting was six non-government community welfare service organisations operating in New South Wales, Australia. Eleven social services offered by these organisations participated. Thirty two clients participated in six client focus groups, 35 staff participated in six staff focus groups and eight manager telephone interviews were conducted. Results. Clients indicated that the cost of nicotine replacement therapy was a barrier to its use and that financial incentives were acceptable. Of the 16 possible strategies listed in the exit survey, the three selected as the most preferred by clients incorporated financial or non-financial assistance. By contrast, staff and managers selected financial and non-financial incentives as the least preferred and least feasible strategies. Discussion and Conclusions. The study found high acceptance of incentives as a smoking cessation strategy among a disadvantaged group of non-government welfare service clients. The comparatively low level of desirability and feasibility from the perspective of service staff and managers suggests implementation of such an approach within the community service setting requires careful further testing.

Brener L; Treloar CJ. Alcohol and other drug treatment experiences of hepatitis C-positive and negative clients: Implications for hepatitis C treatment. Australian Health Review 33(1): 100-106, 2009. (36 refs.)

To assess whether HCV-positive clients perceive that alcohol and other drug (AOD) staff discriminate against them, this study compared the treatment experiences of 120 HCV-positive clients with those of 120 HCV-negative clients attending the same AOD treatment facility. Despite the overall findings of favourable attitudes of HCV-positive clients toward their health care workers, these attitudes were less positive than those of their HCV-negative counterparts. Clients with HCV also rated their interpersonal treatment by their health care workers less favourably. These findings suggest that HCV-positive clients' attitudes towards their health care workers and their experiences of differential treatment by these health care workers might be a barrier to HCV treatment uptake in AOD treatment facilities.

Brener L; von Hippel W; von Hippel C; Resnick I; Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: Utility of a mixed methods approach. Drug and Alcohol Review 29(5): 491-497, 2010. (52 refs.)

Introduction and Aims. Staff interactions with their clients are an important factor in the quality of care that is provided to people in drug treatment. Yet there is very little research that addresses staff attitudes or clients' perceptions of discrimination and prejudice by staff with regard to treatment outcomes. This research aimed to assess whether perceptions of discrimination by staff predict drug treatment completion. Design and Methods. The study used a mixed methods approach. Ninety-two clients in residential rehabilitation facilities in Sydney were administered a series of quantitative measures assessing drug history, severity of drug use, treatment history, perceptions of staff discrimination and treatment motivation. Clients were followed up regularly until an outcome (dropout or completion) was obtained for the full sample. Results. Perceptions of discrimination were a significant predictor of treatment completion, with greater perceived discrimination associated with increased dropout. Qualitative interviews with 13 clients and eight health-care workers from these treatment services were then conducted to gain insight into how perceived discrimination may impact on treatment experiences. Clients and staff discussed how they would address the issue of perceived discrimination during the current treatment experience. Discussion and Conclusions. Adopting a mixed methods approach facilitated exploration of the impact of perceived discrimination on treatment from both clients' and health-care workers' perspectives. This methodology may also enhance interpretation and utilisation of these findings in drug treatment.

Burrow-Sanchez JJ; Jenson WR; Clark E. School-based interventions for students with substance abuse. Psychology in the Schools 46(3): 238-245, 2009. (34 refs.)

Experimentation with substances is typical for many young people, but unfortunately some will go on to develop substance abuse problems that substantially affect their lives. Successfully intervening with students who use or abuse substances is a challenge for school mental health professionals across the nation. There is a need for evidence-based practices that school professionals can use when working with students who have substance abuse problems. This article provides school professionals in secondary settings with current information on student substance use rates, evidence-based individual and group interventions, and discussion of the 42 Code of Federal Regulations, Part 2 (42 CFR).

Bywood P; Lunnay B; Roche A. Effectiveness of opinion leaders for getting research into practice in the alcohol and other drugs field: Results from a systematic literature review. (review). Drugs: Education, Prevention and Policy 16(3): 205-216, 2009. (32 refs.)

Aims: To evaluate the effectiveness of opinion leaders for changing practitioners' behaviour; and determine how this strategy may be used to bridge the research-to-practice gap in the alcohol and drugs (AOD) field. Methods: A systematic literature review was undertaken to assess the use of opinion leaders for improving professional practice. Electronic databases, relevant websites, specialty journals and reference lists of included studies were searched systematically (1966-March 2005). Included studies were critically appraised according to level and quality of evidence and data on effectiveness of opinion leaders were extracted, tabulated and synthesized. Results: Four papers met the inclusion criteria for this review, including one existing systematic literature review comprising eight studies. Since no included studies were conducted in an AOD context, evidence was drawn from the broader medical and health fields. Overall, opinion leaders had variable effectiveness in changing professional practice. For the most part, studies lacked methodological quality and results were prone to bias. Conclusions: Despite good theoretical underpinnings for the use of opinion leaders to influence change in professionals' behaviour, current evidence of their effectiveness is sparse and inconsistent. There is a need for good quality, well-designed studies that are conducted in an AOD context using opinion leaders who are appropriately identified and adequately supported.

Carise D; Brooks A; Alterman A; McLellan AT; Hoover V; Forman R. Implementing evidence-based practices in community treatment programs: Initial feasibility of a counselor "Toolkit". Substance Abuse 30(3): 239-243, 2009. (0 refs.)

Community substance abuse treatment programs face many barriers to adopting "evidence-based" therapies. Training budgets are inadequate to permit acquisition of complex skills, there is little clinical supervision available, and almost all counseling is done in group sessions. The authors adopted an approach widely used in the teaching field -- developing a resource "toolkit" for a specific topic, in this case, a Decisional Balance exercise often used in the evidence-based treatment approach of Motivational Interviewing. This trial toolkit was comprised of a DVD (televised during group to illustrate the clinical concept), a laminated counselor guide (to provide guidance and talking points for the counselor during group), and some worksheets and wallet cards for patients to retain key points (see Table 1). A feasibility trial assessed the acceptability, and sustainability of the "Decisional Balance" concept toolkit among 26 counselors and 210 of their patients, from 6 community-based substance abuse treatment programs. The great majority of patients (97%) and all counselors (100%) reported they were satisfied with the toolkit session; 84% of patients said they would like more groups like the toolkit session. Almost all counselors (96%) were still using at least one component of the toolkit 3 months after their initial exposure with no prompting. The toolkit curriculum-based approach may be a viable and attractive way of translating core concepts from sophisticated evidence-based therapies into use by counselors within contemporary, community-based treatment programs with minimal training.

Carroll KM; Martino S; Rounsaville BJ. No Train, No Gain? (editorial). Clinical Psychology: Science and Practice 17(1): 36-40, 2010. (20 refs.)

What kind of training is needed for what type of clinician to deliver what type of therapy? Beidas and Kendall's (2010) well-considered recommendations for further research into systematic strategies for training clinicians to utilize evidence-based treatments highlight the limitations of didactic training alone (without supervision, fidelity monitoring, and feedback) in conferring specific skills to clinicians. To further amplify some of the points made, we summarize findings from our recent series of trials, which involved training community-based addiction clinicians to perform evidence-based therapies in a multisite randomized clinical trial. In particular, review of tapes from the "treatment as usual" condition in that study suggests that (a) delivery of interventions associated with evidence-based treatment was infrequent, (b) clinicians overestimated the time spent on evidence-based interventions, and (c) ongoing supervision and performance-based feedback appear to suppress time spent in session on discourse unrelated to the patient's problems and concerns. We also discuss computer-assisted treatment and computer-assisted clinician training as important new tools for disseminating evidence-based therapies.

Christie G; Merry S; Robinson E. Do young people attending addiction services differ from those attending youth mental health services? Drug and Alcohol Review 29(4): 406-412, 2010. (50 refs.)

Introduction and Aims. We aimed to describe and compare the self-reported substance use, psychopathology and psychosocial morbidity in adolescents attending two adolescent outpatient services, a triage-based mental health service and an engagement-focused addiction service in Auckland, New Zealand. Design and Methods. A naturalistic cross-section of 131 (addiction service = 67, mental health service = 64) 14-18-year-old boys and girls attending each service completed a standardised screening and assessment instrument, the Drug Use Screening Inventory-Revised. The Drug Use Screening Inventory-Revised measures self-reported problems across 10 domains of functioning, including substance use, behaviour, psychiatric symptoms and school and family functioning. Descriptive statistics were used to provide an overview of the self-reported morbidity in each group and t-tests were used to determine differences between the two groups. Results. Adolescents attending the addiction service reported significantly more problems with substance use, school performance and peer relationships than those attending the mental health service. There was no significant difference in reported psychiatric symptoms, behavioural problems, social competency, health problems, family problems, difficulties in work functioning or leisure time between the two groups. Discussion and Conclusions. Young people presenting to engagement-focused substance use services report similar difficulties to those at mental health services across most areas of psychosocial functioning. Addiction services may require equivalent staffing expertise and workforce development to that in mental health to effectively meet young people's needs.

Chun J; Guydish JR; Delucchi K. Does the presence of a smoking cessation clinical triad affect staff practices related to smoking? Journal of Drug Issues 39(2): 385-400, 2009. (46 refs.)

This study investigated whether organizational changes occurred when nicotine treatments were tested in specialty care clinics. Two intervention clinics (one drug treatment and one HIV-care) participated in clinical trials for nicotine treatment. Three clinics (two drug and one HIV-care) were control clinics. Staff in the intervention clinics (n=57) and in the control clinics (n=62) were surveyed at baseline and 18 months later. Staff surveys concerned nicotine-related knowledge, beliefs about treating smoking, self-efficacy in delivering such treatment, nicotine related practices, and barriers to providing nicotine treatment. Mean scale scores at 18 months were no different in clinics participating in the clinical trials from the control group for any of the five scales (knowledge, practices, barriers, efficacy, and beliefs). The presence of a smoking cessation clinical trial did not influence staff knowledge, attitudes, or practices related to smoking in these clinics. More specific organizational intervention may influence staff practices related to addressing smoking among clients in drug treatment and HIV-care clinics.

Cleary M; Hunt GE; Matheson S; Walter G. Views of Australian mental health stakeholders on clients' problematic drug and alcohol use. Drug and Alcohol Review 28(2): 122-128, 2009. (33 refs.)

Introduction and Aims. Substance misuse by people with a serious mental illness may exacerbate psychiatric symptoms and contribute to relapse. The aim of the study was to ascertain the views of a wide range of Australian mental health service providers on staff education and training, client contact and management, assessment, and treatment effectiveness and service delivery. Design and Methods. A survey was sent to a sample of 171 mental health stakeholders in Australia identified through internet searches, state and territory mental health departments and professional organisations. Results. Of the 66 respondents (39% response rate), the substances identified to be most problematic were alcohol and cannabis. Integrated service models of treatment were identified as the most preferable and effective. Barriers to treatment included client motivation to reduce substance use, poor communication and coordination between treatment services, and lack of specific services for dual diagnosis clients. Almost all indicated a need for further training in the area of dual diagnosis. Discussion and Conclusions. Dual diagnosis is common and the reality is that this vulnerable clientele will continue to challenge service providers and treatment approaches into the foreseeable future. Issues include the organization and delivery of treatment services, education and training, resource allocation, collaboration between treatment agencies and clinically relevant research evaluating the effectiveness of practice. It is thus surprising that with so much investment in this area the majority of stakeholders are still dissatisfied with access to and the level of care for dual diagnosis clients.

Clutterbuck R; Tobin D; Orford J; Copello A; Preece M; Birchwood M et al. Exploring the attitudes of staff working within mental health settings toward clients who use cannabis. Drugs: Education, Prevention and Policy 16(4): 311-327, 2009. (39 refs.)

Aims: This study aimed to explore the attitudes of staff working within mental health settings toward cannabis in general and cannabis use in individuals with severe mental-health problems. Method: Twenty members of staff working within community mental health teams in Birmingham, UK, were interviewed using qualitative research methods. The overarching themes within the staff accounts are described and the interrelationship between themes explored. Findings: Staff use an 'individualized' approach when working with cannabis-using clients dependent on a number of key components, including the positive and negative effects of use, wider evidence base, client vulnerability, engagement, professional and personal views and harm reduction. It is suggested that any approach staff may take toward cannabis use at any one time is greatly dependent upon the above factors and these factors are highly client specific. Conclusions: The findings may help to explain why interventions aimed at reducing substance use in people with psychosis might prove less successful when targeting cannabis use.

Crits-Christoph P; Hamilton JL; Ring-Kurtz S; Gallop R; McClure B; Kulaga A et al. Program, counselor, and patient variability in the alliance: A multilevel study of the alliance in relation to substance use outcomes. Journal of Substance Abuse Treatment 40(4): 405- 413, 2011. (30 refs.)

We explored patient, therapist, and program variability in the alliance in relation to drug and alcohol use during treatment, and whether alliance mediates the relation of program characteristics to drug/alcohol use. Data (N = 1,613 patients) were drawn from a randomized clinical trial investigating the efficacy of an intervention that provided alliance and outcome feedback to 112 counselors across 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Program characteristics were measured using the Organization Readiness for Change scale. Using multilevel modeling, we found that alliance was related to both drug and alcohol use during the past week at the patient and program levels of analysis, but not the counselor level. Several program characteristics were related to average drug and alcohol use. The alliance was not a mediator of these relationships. Program variability in the alliance is important to the alliance outcome relationship in the treatment of substance abuse. Better outcomes can be achieved by improving both organizational functioning and the patient counselor alliance.

Curtis SL; Eby LT. Recovery at work: The relationship between social identity and commitment among substance abuse counselors. Journal of Substance Abuse Treatment 39(3): 248-254, 2010. (43 refs.)

The complex makeup of the substance abuse treatment workforce poses unique challenges to the field. One interesting dynamic is the high rate of counselors who are personally recovering from addictions. Based on social identity theory, it was expected that counselors working in the field of substance abuse treatment who are in recovery themselves will identify more with their profession and report higher professional and organizational commitment. Data from a study of substance abuse counselors from across the United States support the proposed relationship between personal recovery status and professional commitment but not organizational commitment.

Davis MF; Shapiro D; Windsor R; Whalen P; Rhode R; Miller HS et al. Motivational interviewing versus prescriptive advice for smokers who are not ready to quit. Patient Education and Counseling 83(1): 129-133, 2011. (26 refs.)

Objective: Smokers who are not ready to quit are a very difficult group to treat. Physicians, nurses, and nurse practitioners are in a unique position to encourage patients to quit smoking. However, the best approach to do so is not clear. Methods: A two-group randomized controlled trial with 218 pack-a-day precontemplative and contemplative smokers recruited from the community. The laboratory-based study was designed to simulate outpatient visits to general practitioners. Participants were randomized to a 15-min intervention to compare the effectiveness of brief motivational or prescriptive counseling by a health professional. Thirteen outcome variables included intentions to quit and verbal reports at 1 and 6 months with biological verification. A composite outcome measure was constructed to provide greater power to detect study differences. Results: Approximately 33% of the sample reported at least one 24-h quit period during the 6 months they were followed after the trial. Results suggest that while neither treatment was superior, there were subgroup differences. Participants in the motivational condition were also more likely to respond to follow-up calls. Conclusions and practice implications: Motivational interviewing and prescriptive advice were equally effective for precontemplative and contemplative smokers. Practitioners should use the method that appeals to them.

de Vargas D. Reduced version of the Scale of Attitudes toward Alcohol, Alcoholism and Alcoholics: Primary results. Revista da Escola De Enfermagem da USP 45(4): 912-919, 2011. (18 refs.)

This study aimed to analyze the items of the Scale of Attitudes toward Alcohol, alcoholism and alcoholics in order to prepare a reduced version keeping the instrument's psychometric properties. The preliminary version of the Scale composed by 165 items was tested in a sample with 144 nursing student. The evaluation process of the items consisted of the total-item coefficient correlation and reliability of the instrument was estimated by Cronbach's alpha coefficient. Results indicate the permanence of 83 items, divided into five factors that showed satisfactory values in the different coefficients of internal consistency. Further studies are needed with larger samples in order to give continuity to the process of scale validation among health professionals.

Decker SE; Jameson MT; Naugle AE. Therapist training in empirically supported treatments: A review of evaluation methods for short- and long-term outcomes. (review). Administration and Policy in Mental Health and Mental Health Services Research 38(4, special issue): 254-286, 2011. (126 refs.)

Therapist training efforts have been assessed using several outcomes. A model for evaluating therapist training in empirically supported treatments is presented, adapted from Kirkpatrick's (in: Craig and Bittel (eds.) Training and development handbook, 1967) training evaluation model. The adapted framework includes short-term outcomes, such as reactions to training and changes in attitude, knowledge, or skills, and longer-term outcomes, such as changes in therapist behavior in practice or client outcomes. Evaluation methods for these outcomes are reviewed, with information on their validity, reliability, and feasibility. An agenda for further research to improve therapist training evaluation is presented, with discussion of how evaluation can inform other areas of the field.

Deering DEA; Sheridan J; Sellman JD; Adamson SJ; Pooley S; Robertson R et al. Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness. Addictive Behaviors 36(6, special issue): 636- 642, 2011. (42 refs.)

In New Zealand approximately 4600 people receive opioid substitution treatment (OST) for opioid dependence, primarily methadone maintenance treatment. This study explored ways in which OST could be improved, given the significant waiting times for treatment. Two parallel surveys were conducted: 1) peer interviews with 85 regular daily or almost daily opioid drug users (51.8% receiving OST, 18.8% not currently receiving OST, and 29.4% never received OST) and: 2) a census of all 18 specialist OST service providers. When asked how OST might be improved, the four categories most commonly cited by the opioid users were 'better treatment by staff, 'more flexibility', 'better takeaway arrangements', and 'decreased waiting time'. Both opioid users and specialist services rated 'restricted takeaways' and 'having to go on a waiting list' in the top three perceived barriers to OST. Almost all services reported significant resource issues and barriers to the transfer of stable clients from specialist services to continuing treatment in primary care. The findings from this study indicate how OST can be made more accessible and attractive and thus achieve better uptake and retention.

DeLong GG. Initial validation of a Brief Individual Readiness for Change Scale (BIRCS) for use with addiction program staff practitioners. Journal of Social Work Practice in the Addictions 9(2): 184-203, 2009

The Brief Individual Readiness for Change Scale is a rapid assessment tool for use with addiction program staff practitioners and social workers. Technology transfer and research-to-practice readiness are essential to programs and practitioners faced with implementing evidence-based practice techniques and showing positive outcomes. The focus of scale development to date has been global assessment of organizational readiness for change. A crucial, although frequently overlooked, element of technology transfer success is readiness for change of individual practitioners who are relied on to implement the new techniques. The ability to identify and ameliorate points of practitioner resistance prior to implementation of these techniques is a key to avoiding frustration, low staff morale, and poor outcomes. This study attempts to establish initial psychometrics of a brief scale to screen for practitioner's readiness for change. It is based on a sample of 594 addiction practitioners in 2 Southern states.

Delucchi KL; Tajima B; Guydish J. Development of the Smoking Knowledge, Attitudes, Practices (S-KAP) Instrument. Journal of Drug Issues 39(2): 347-363, 2009. (41 refs.)

This report describes the development and measurement characteristics of a new measure of smoking knowledge, attitudes, and practices (S-KAP) among treatment providers. Data are based on survey responses from 336 paid staff working in one of three drug abuse treatment or HIV care settings. Exploratory factor analysis, used to examine the factor structure, pointed towards five underlying factors: a single "knowledge" factor, three "attitude" factors ('treatment barriers,' 'counselor self-efficacy,' and 'counselor attitudes) and a single "practices" factor. The Knowledge scale had a standardized Cronbach's alpha coefficient of. 85. The coefficients for Barriers, Self-Efficacy, and Attitudes were. 81,. 72, and. 74, respectively. The Practice scale had a standardized Cronbach's alpha coefficient of. 91. These results indicate that the proposed scales have reasonably good psychometric characteristics and will allow researchers to quantify staff knowledge, attitudes, and practices regarding smoking cessation treatments and issues.

Dolan SL; Justus A; LaChance HR; MacKillop J; MacPherson L; McGeary J et al. Alcohol Education Inventory-Revised: What every mental health professional should know about alcohol. Journal of Substance Abuse Treatment 37(1): 41-53, 2009. (9 refs.)

In 1995, Miller and C'de Baca created a 50-item measure, the Alcohol Education Inventory (AEI), to assess mental health professionals' basic knowledge of alcohol and alcohol problems. The purpose of this study was to update the AEI based on advances in the field since its publication. The AEI-Revised (AEI-R) consists of 13 of the original AEI items, 30 items that were revised and updated, and 7 new items. The AEI-R was administered to 90 mental health trainees with percentage correct ranging from 60% (psychology postdoctoral fellows) to 70% (psychiatry residents). The percent correct is very similar to that found on the original AEI (64%-70%). Survey results suggest that alcohol-related knowledge by mental health professionals in general training is less than adequate. The AEI-R may be useful as a tool to assess basic knowledge of alcohol among mental health professionals.

Durand MA; Lelliott P; Crome I; Coyle N. The number, deployment, activities and attitudes of specialist consultant addiction psychiatrists in England: A national survey. Drugs: Education, Prevention and Policy 16(1): 71-87, 2009. (30 refs.)

Aims: Problematic drug and alcohol use imposes a considerable burden on health and social services in England. Although consultant addiction psychiatrists are considered to play a central role in the provision of treatment services to people with substance misuse problems, little is known about their number, deployment or roles and responsibilities. This study aimed to address this. Methods: This three-stage study comprised a mapping exercise, in-depth interviews and focus groups, and a postal survey of consultant addiction psychiatrists undertaken in March 2005. The latter included questions about working arrangements, views about priorities, attitudes about roles, and retirement intentions. Findings: The mapping exercise identified 126 consultant addiction psychiatrists working in England; this equates to about 117 whole time equivalents (wte). The number is about one quarter of the minimum recommended by the Royal College of Psychiatry. Rate of recruitment to the specialty is sufficient to maintain numbers at existing levels. Eighty-five consultant addiction psychiatrists responded to the survey (67% of those identified). All but one are members of a multi-disciplinary team. Only 8 consultants (9%) work in a specialist alcohol service. The respondents spent an average of 19 hours per week in direct clinical work and 9 hours on management activities. Many would wish to have more time for teaching, research and clinical audit. Most consultants agree that they should see mainly the most complex cases and that they should lead, and be a resource for, the multi-disciplinary team. Consultants believe that they give higher priority to certain patient groups than do commissioners of services and, in particular, to people with severe alcohol dependence and young people. Nearly three quarters feel under pressure to meet unrealistic performance standards and targets. More than 80% think that addiction psychiatrists, as a professional group, have not been sufficiently involved in setting national policy. Although 92% think that the specialty is a rewarding career for trainees, about one half agree that addiction psychiatrists are an 'endangered species'. Conclusions: Consultant addiction psychiatrists are playing the clinical role envisaged by the Department of Health and the Royal College of Psychiatry. Their low numbers, however, mean that they cannot contribute fully to teaching, training, research or service development.

Eby LT; Burk H; Maher CP. How serious of a problem is staff turnover in substance abuse treatment? A longitudinal study of actual turnover. Journal of Substance Abuse Treatment 39(3): 264-271, 2010. (33 refs.)

In the substance abuse treatment field, the annual turnover rate is cited as being anywhere between 19% and 50% (J.A. Johnson & P. M. Roman, 2002; S.L. Gallon, R.M. Gabriel, J.R.W. Knudsen, 2003; H.K. Knudsen, J.A. Johnson, & P.M. Roman, 2003; A.T. McLellan, D. Carise, & H.D. Kleber, 2003). However, no research to date has evaluated these claims by tracking turnover longitudinally using organizational turnover data from substance abuse treatment centers. This research presents the results of a longitudinal study designed to systematically examine actual turnover among counselors and clinical supervisors. Twenty-seven geographically dispersed treatment organizations, serving a wide range of clients in the public and private sector, provided data for the study over a 2-year time span (2008-2009). The annual turnover rate was 33.2% for counselors and 23.4% for clinical supervisors. For both groups, the majority of turnover was voluntary (employee-initiated). Specific reasons for turnover were largely consistent across the two groups, with the most common reason being a new job or new opportunity. The findings are discussed in terms of the unique employment context of substance abuse treatment. Practical recommendations are also discussed to help stem the tide of turnover in the field of substance abuse treatment.

Ekendahl M. The limits of legitimacy: Service providers' views on maintenance treatment in Sweden. Addiction Research & Theory 19(5): 427-437, 2011. (64 refs.)

Background: It is widely acknowledged that the social meaning of maintenance treatment (MT) with methadone is context-dependent and that different discourses influence how this approach to opiate addiction problems is practised. In Sweden, MT has long been ideologically controversial, even if the past decade's emphasis on evidence-based interventions has made it more accepted and prevalent in the treatment system. MT may thus be seen as a discursive field where science and values are intertwined and impact practice jointly, which emphasises the importance of analysing how MT is attributed with meaning. Objectives: The study aims to identify and analyse the discourses that service providers in Swedish opiate addiction treatment refer to in their efforts to legitimise MT. Methods: Twenty-eight interviews focused on MT-related issues were conducted with Swedish social workers and health care workers. The material was analysed qualitatively according to discourse theory. Findings: Three key features of MT were identified: as therapeutic intervention; as beyond harm reduction and as pragmatic solution. The respondents constructed MT as a necessary medical and psychosocial treatment aimed at rehabilitation and patients' complete break with drug abuse, which reflects a policy-context where solutions to drug problems are supposed to be resolute, thorough and abstinence-oriented. Conclusions: The service providers handled the controversy between science and values by drawing on a decent-life discourse, where opiate addiction problems are solved with a pragmatic stance towards evidence and where only interventions that make patients' lives allegedly decent are considered legitimate (excluding, e. g. heroin prescription and liberal methadone distribution).

Fussell H; Haaken J; Lewy CS; McFarland BH. Clinical perception: A study of intimate partner violence versus methamphetamine use as presenting problems. Psychiatry. Interpersonal and Biological Processes 72(4): 382-392, 2009. (15 refs.)

This study draws on theory by Solomon Asch (1946, 1952) to examine how presenting with intimate partner violence versus methamphetamine use shapes characteristics of substance abuse assessment interviews. When responding to an initial open-ended question from a substance abuse counselor, the methamphetamine user and intimate partner violence survivor may elicit very different reactions from the counselor. We predicted that these differing presenting problems would initiate different trajectories for overall impression formation. To test this hypothesis, 18 substance abuse practitioners interviewed one standardized patient (an actor portraying a substance abuse client) who alternated her presenting problem between a) violence in a domestic setting and b) methamphetamine use. The remainder of her story was identical for counselors in either presenting problem group. Results included differences between the two groups in median length of the interviews and failure of both groups to explore domestic violence as a co-occurring problem. Clinical practices related to substance abuse counseling and intimate partner violence are discussed in light of these findings.

Galvani S; Hughes N. Working with alcohol and drug use: Exploring the knowledge and attitudes of social work students. British Journal of Social Work 40(3): 946-962, 2010. (27 refs.)

Many social workers in the UK work daily with the social harms linked to problematic substance use. Historically, however, their drug and alcohol training needs have been overlooked. This study set out to achieve two key objectives: (i) to assess social work students' knowledge of, and attitudes towards, working with people with substance problems; and (ii) to develop and test a questionnaire to meet this objective. A four-part self-completion questionnaire was developed and administered to a purposive sample of 156 social work students. The focus of this article will be on the results of Part 2 of the pilot survey, which focused on the students' attitudes towards, and knowledge of, substance use. One hundred and twenty-one completed questionnaires were used as the basis for analysis. Three factors emerged as the key explanatory factors demonstrating significant relationships between them: 'knowledge', 'support from colleagues' and 'legitimacy of role'. Social work training needs to recognize the need for alcohol and drug education within social work qualifying programmes in order that future social workers will feel equipped with the knowledge and legitimacy to do their job and meet the needs of people who have problems with alcohol and drugs.

Gilchrist G; Moskalewicz J; Slezakova S; Okruhlica L; Torrens M; Vajd R et al. Staff regard towards working with substance users: A European multi-centre study. Addiction 106(6): 1114- 1125, 2011. (57 refs.)

Aims: To compare regard for working with different patient groups (including substance users) among different professional groups in different health-care settings in eight European countries. Design: A multi-centre, cross-sectional comparative study. Setting: Primary care, general psychiatry and specialist addiciton services in Bulgaria, Greece, Italy, Poland, Scotland, Slovakia, Slovenia and Spain. Participants: A multi-disciplinary convenience sample of 866 professionals (physicians, psychiatrists, psychologists, nurses and social workers) from 253 services. Measurements: The Medical Condition Regard Scale measured regard for working with different patient groups. Multi-factor between-subjects analysis of variance determined the factors associated with regard for each condition by country and all countries. Findings: Regard for working with alcohol (mean score alcohol: 45.35, 95% CI 44.76, 45.95) and drug users (mean score drugs: 43.67, 95% CI 42.98, 44.36) was consistently lower than for other patient groups (mean score diabetes: 50.19, 95% CI 49.71, 50.66; mean score depression: 51.34, 95% CI 50.89, 51.79) across all countries participating in the study, particularly among staff from primary care compared to general psychiatry or specialist addiction services (P < 0.001). After controlling for sex of staff, profession and duration of time working in profession, treatment entry point and country remained the only statistically significant variables associated with regard for working with alcohol and drug users. Conclusions: Health professionals appear to ascribe lower status to working with substance users than helping other patient groups, particularly in primary care; the effect is larger in some countries than others.

Gray D; Saggers S; Wilkes E; Allsop S; Ober C. Managing alcohol-related problems among Indigenous Australians: What the literature tells us. Australian and New Zealand Journal of Public Health 34(Supplement 1): S34-S35, 2010. (14 refs.)

Objective: To contextualise and provide an overview of two review papers - prepared as part of a larger research program - dealing with different aspects of the treatment of Indigenous Australians with alcohol-related problems. Method: The papers were reviewed thematically and compared to identify key issues raised in them. Findings: Together, the papers highlight the paucity of the evidence base for the provision of treatment for Indigenous Australians with alcohol-related problems. Among the key issues identified are: the need to engage with clients in culturally safe ways; practitioner, organisational and client barriers to engagement; the contexts in which Indigenous drinking and treatment take place; the need to develop rigorous methods of evaluation more appropriate to Indigenous cultural and service provision settings; and the importance of effective partnerships in the provision of services. Conclusion: For those working in the field, the reviews direct attention to the need to review and interrogate our current practice. They also provide clear directions for future research.

Harris AHS; Reeder RN; Ellerbe LS; Bowe TR. Validation of the treatment identification strategy of the HEDIS addiction quality measures: Concordance with medical record review. (review). BMC Health Services Research 11: e73, 2011. (10 refs.)

Background: Strategies to accurately identify the occurrence of specific health care events in administrative data is central to many quality improvement and research efforts. Many health care quality measures have treatment identification strategies based on diagnosis and procedure codes - an approach that is inexpensive and feasible but usually of unknown validity. In this study, we examined if the diagnosis/procedure code combinations used in the 2006 HEDIS Initiation and Engagement quality measures to identify instances of addiction treatment have high concordance with documentation of addiction treatment in clinical progress notes. Methods: Four type of records were randomly sampled from VHA electronic medical data: (a) Outpatient records from a substance use disorder (SUD) specialty clinic with a HEDIS-qualified substance use disorder (SUD) diagnosis/CPT code combination (n = 700), (b) Outpatient records from a non-SUD setting with a HEDIS-qualified SUD diagnosis/CPT code combination (n = 592), (c) Specialty SUD Inpatient/residential records that included a SUD diagnosis (n = 700), and (d) Non-SUD specialty Inpatient/residential records that included a SUD diagnosis (n = 700). Clinical progress notes for the sampled records were extracted and two raters classified each as documenting or not documenting addiction treatment. Rates of concordance between the HEDIS addiction treatment identification strategy and the raters' judgments were calculated for each record type. Results: Within SUD outpatient clinics and SUD inpatient specialty units, 92% and 98% of sampled records had chart evidence of addiction treatment. Of outpatient encounters with a qualifying diagnosis/procedure code combination outside of SUD clinics, 63% had chart evidence of addiction treatment. Within non-SUD specialty inpatient units, only 46% of sampled records had chart evidence of addiction treatment. Conclusions: For records generated in SUD specialty settings, the HEDIS strategy of identifying SUD treatment with diagnosis and procedure codes has a high concordance with chart review. The concordance rate outside of SUD specialty settings is much lower and highly variable between facilities. Therefore, some patients may be counted as meeting the 2006 HEDIS Initiation and Engagement criteria without having received the specified amount (or any) addiction treatment.

Hayes-Roth B; Saker R; Amano K. Automating individualized coaching and authentic role-play practice for brief intervention training. Methods of Information In Medicine 49(4): 406-411, 2010. (16 refs.)

Objectives: Brief intervention helps to reduce alcohol abuse, but there is a need for accessible, cost-effective training of clinicians. This study evaluated STAR Workshop, a web-based training system that automates efficacious techniques for individualized coaching and authentic role-play practice. Methods: We compared STAR Workshop to a web-based, self-guided e-book and a no-treatment control, for training the Engage for Change (E4C) brief intervention protocol. Subjects were medical and nursing students. Brief written skill probes tested subjects' performance of individual protocol steps, in different clinical scenarios, at three test times: pre-training, post-training, and post-delay (two weeks). Subjects also did live phone interviews with a standardized patient, post-delay. Results: STAR subjects performed significantly better than both other groups. They showed significantly greater improvement from pre-training probes to post-training and post-delay probes. They scored significantly higher on post-delay phone interviews. Conclusion: STAR Workshop appears to be an accessible, cost-effective approach for training students to use the E4C protocol for brief intervention in alcohol abuse. It may also be useful for training other clinical interviewing protocols.

Hill RG; Atnas CI; Ryan P; Ashby K; Winnington J. Whole team training to reduce burn-out amongst staff on an in-patient alcohol ward. Journal of Substance Use 15(1): 42-50, 2010. (24 refs.)

In 2005 the alcohol in-patient ward at South London and Maudsley NHS Foundation Trust participated in a 2-day training programme designed to reduce levels of burn-out amongst staff. The training intervention was derived from a large-scale project that focused on in-patient and community mental health staff in five European countries. A research component was built into the work, with levels of staff burn-out being measured prior to the training intervention and 1 month afterwards, using the Maslach Burn-out Inventory (MBI). The team were able to identify four sources of stress at work. A 1-month follow-up using the MBI showed that levels of emotional exhaustion and depersonalization had been reduced and feelings of personal accomplishment at work risen. Staff identified four main sources of stress at work. These were: (i) group-work; (ii) dealing with complex clients; (iii) effectively evaluating the shift; and (iv) client aggression. The implications of whole team training is discussed in the context of staff working with high turnover clients.

Hogue A. When technology fails: Getting back to nature. (editorial). Clinical Psychology: Science and Practice 17(1): 77-81, 2010. (30 refs.)

Research on substance use disorders has produced a slew of disappointments in studies designed to confirm basic principles of the technology approach to treatment dissemination. These setbacks should inspire addictions science to pursue complementary paths of inquiry that focus on evidence-based practices delivered under naturalistic conditions. This will require larger accommodations to, and closer partnerships with, the indigenous cultures of everyday care.

Islam MM; Conigrave KM; Stern T. Staff perceptions of syringe dispensing machines in Australia: A pilot study. Substance Use & Misuse 44(4): 490-501, 2009. (22 refs.)

Background/Aims: Syringe dispensing machines were introduced into needle syringe programs (NSPs) two decades ago. The few published studies on dispensing machines have focused on feedback of machine users and service providers' feedback has rarely been reported. This study obtained the feedback of health staff of NSPs, other sectors of Drug Misuse Treatment Services and of other health services adjoining dispensing machines on the role and effectiveness of dispensing machines. Methods: Between August and November 2006, questionnaires were anonymously completed by NSP and drug misuser treatment staff in an Area Health Service in Sydney, as well as by the staff of two nondrug-related health services located adjacent to needle syringe dispensing machines. The questionnaire was available in either paper or Internet based forms. Results: Almost 80% of 94 participants rated dispensing machines as either moderately successful or successful in reducing sharing of needles and syringes. Staff considered that introduction of these machines to NSPs had improved services for injecting drug users without increasing unsafe disposal of used equipment, community drug use, or vandalism. However 78% of respondents felt that dispensing machines either reduce or may reduce IDUs' opportunity for staff contact and hence opportunity for engagement or education. The study limitations were noted. Conclusion: Syringe dispensing machines are perceived to be a successful and appropriate outlet of NSPs that complement other outlets. Lack of staff-user contact was seen as their main disadvantage.

Joe GW; Simpson DD; Rowan-Szal GA. Interaction of counseling rapport and topics discussed in sessions with methadone treatment clients. Substance Use & Misuse 44(1): 3-17, 2009. (29 refs.)

Therapeutic rapport between counselors and clients in drug user treatment has been shown to be an important predictor of follow-up outcomes. This naturalistic study investigated the relationship of counseling rapport to drug-related topics discussed in counseling sessions in a sample of 330 clients and nine counselors. These voluntary clients had been admitted to a private, for-profit outpatient methadone treatment in Texas between September 1995 and August 1997 and received no-fee services for a year for participation in this study. The data were gathered using forms in the TCU community treatment assessments (www.ibr.tcu.edu) that measured intake information, counseling session topics, and counselor evaluation of the client. A majority were males, Hispanic, had a pending legal status and the average age was 39. Co-occurring drug dependence for these heroin users included cocaine (38%) and alcohol (31%). The results supported the hypothesis that higher rapport would be associated with addressing clients in a more supportive approach that emphasized relapse prevention and strengths-building while lower rapport would be associated with a punitive counseling style that stressed program rules and compliance. The influences of client background, counselor differences, and during-treatment positive urines were also examined. Although counselors differed in their general manner of dealing with clients, each also showed flexibility determined in part by client behavior (such as continued cocaine use). The findings indicate that focusing on constructive solutions is the preferred counseling approach.

Joosten EAG; De Weert-Van Oene GH; Sensky T; Van Der Staak CPF; De Jong CAJ. Treatment goals in addiction healthcare: The perspectives of patients and clinicians. International Journal of Social Psychiatry 57(3): 263- 276, 2011. (30 refs.)

Background: Little is known about the perspectives of either patients or clinicians regarding treatment goals in addiction healthcare. In general, treatment goals involve abstinence or at least reduction of substance use. Aim: To examine and compare the treatment goals indicated by both patients and clinicians at baseline, interim and exit measurement. Method: A descriptive study was performed with multiple measurements of treatment goals. Patients (n = 111) and clinicians (n = 20) were recruited from three addiction treatment centres in the Netherlands. A Shared Decision Making Intervention (SDMI) was undertaken to promote and evaluate treatment agreement. Results: Patients identified treatment goals of daytime activities and abstinence or reduced alcohol consumption as most important. Clinicians indicated psychological distress, daytime activities and substance use as most important. Differences between patients and clinicians were found for the treatment goals of physical health (patient > clinician) and psychological distress (clinician > patient). The results further showed that treatment goals of both patients and clinicians become more closely aligned during the course of treatment. Conclusion: SDMI provides a method to explore and discuss discrepancy between patients' and clinicians' goals of treatment which leads to convergence. Such convergence is likely to be a necessary prerequisite for positive treatment outcomes.

Jordan TR; Khubchandani J; Wiblishauser M; Glassman T; Thompson A. Do respiratory therapists receive training and education in smoking cessation? A national study of post-secondary training programs. Patient Education and Counseling 85(1): 99-105, 2011. (38 refs.)

Objective: To assess the tobacco-related education provided by post-secondary respiratory therapy training programs in the United States. Methods: A cross-sectional research design was used to survey the entire population of program directors of post-secondary, respiratory therapy training programs in the United States. A valid and reliable questionnaire was developed and mailed using a 2-wave mailing technique (73% return rate). Internal reliability coefficients (Cronbach alpha) for the various components of the questionnaire ranged from 0.78 to 0.91. Results: More than half of programs (56%) offered no teaching on the 5R's. Nearly half (47%) offered no teaching on the 5A's. Of the 13 tobacco-related topics listed in the basic science and clinical science sections of the questionnaire, only one topic (i.e., diseases linked to tobacco use) received 3 h or more of instruction by approximately a third of programs (35.8%). The majority of programs (>90%) spent no time teaching students about the socio-political aspects of tobacco use cessation. Moreover, 41% of programs did not formally evaluate students' competence in providing smoking cessation counseling to patients. Conclusions: Tobacco-related education is a very minor component of the education and training received by respiratory therapy students in the United States. Practice Implications: Respiratory therapy training programs in the United States have great potential to strengthen the tobacco-related education that they provide to students. Practicing respiratory therapists would likely benefit from continuing medical education focused on how to use evidence-based smoking cessation counseling techniques with patients.

Kane M; Green D. Substance abuse by elders and self-enhancement bias. Educational Gerontology 35(2): 95-120, 2009. (62 refs.)

Human service professionals regularly do not recognize the symptoms of substance abuse in older populations and are unlikely to provide intervention. In this study, human service students (N=242) were given one of three vignettes in which the main character was an 80-year-old man, an 80-year-old woman, or they were asked to imagine themselves at 80. The vignette character was described as living alone, smelling of alcohol, and whose garbage was filled with empty beer and wine containers. Respondents were asked whether they believed the character had a substance abuse problem, if intervention was appropriate, if the character was depressed or suffering from self-neglect, and if the neighbors should express their concerns to the character. The largest number of respondents perceived that the vignette character may have a drinking problem, may be lonely, and would benefit from professional help. Most did not believe neighbors should express concern or that the character was suffering from self-neglect. Those who completed the vignette in which they were asked to imagine themselves at age 80 were prone to self-enhancement bias. Using the Wilks' Lambda criteria, the General Linear Model was significant (F=1.474, p=.024), with 8 of the 25 items possessing significant p values.

Kishore V; Lynch S; Pichon J; Theall K; Johnson S; Roberson E et al. Knowledge, attitudes and practice relating to hazardous alcohol use across the continuum of care in a community healthcare centre. Drugs: Education, Prevention and Policy 18(1): 60-68, 2011. (20 refs.)

Alcohol screening and intervention in community health settings places a great time demand on practitioners. Thus, implementation of practitioner-delivered intervention is challenging. Aims: The aim of this study was to assess the feasibility of incorporating a brief alcohol intervention into daily practices of a community health care centre by utilizing assistance from non-practitioners and administrative staff. Methods: In regard to alcohol use, the knowledge, attitudes and practice (KAP) of the staff of a health care centre were assessed using a self-administered survey. The 57-item survey consisted of alcohol-relevant questions in four domains: clinical practice, knowledge and self-assessment of skills and available resources. Findings: The sample consisted of 70 individuals-23 practitioners, 21 medical assistants and 26 administrative staff from two New Orleans' clinics. Practitioners were observed to be most confident in assessing alcoholism as well as in implementing interventions for alcohol abuse. Medical assistants exhibited high self-rated scores, second to practitioners, in survey items regarding attitudes towards patients, alcohol knowledge and alcohol-related clinical skills. Conclusions: Based on KAP, it appears that healthcare workers other than practitioners, particularly medical assistants, may serve as a useful resource to practitioners in providing alcohol screening and prevention services. Educationation and empowerment of medical assistants will however be needed to achieve this goal.

Knowlton AR; Arnsten JH; Eldred LJ; Wilkinson JD; Shade SB; Bohnert AS et al. Antiretroviral use among active injection-drug users: The role of patient-provider engagement and structural factors. AIDS Patient Care and STDs 24(7): 421-428, 2010. (54 refs.)

HIV-seropositive, active injection-drug users (IDUs), compared with other HIV populations, continue to have low rates of highly active antiretroviral therapy (HAART) use, contributing to disparities in their HIV health outcomes. We sought to identify individual-level, interpersonal, and structural factors associated with HAART use among active IDUs to inform comprehensive, contextually tailored intervention to improve the HAART use of IDUs. Prospective data from three semiannual assessments were combined, and logistic general estimating equations were used to identify variables associated with taking HAART 6 months later. Participants were a community sample of HIV-seropositive, active IDUs enrolled in the INSPIRE study, a U. S. multisite (Baltimore, Miami, New York, San Francisco) prevention intervention. The analytic sample included 1,225 observations, and comprised 62% males, 75% active drug users, 75% non-Hispanic blacks, and 55% with a CD4 count <350; 48% reported HAART use. Adjusted analyses indicated that the later HAART use of IDUs was independently predicted by patient-provider engagement, stable housing, medical coverage, and more HIV primary care visits. Significant individual factors included not currently using drugs and a positive attitude about HAART benefits even if using illicit drugs. Those who reported patient-centered interactions with their HIV primary care provider had a 45% greater odds of later HAART use, and those with stable housing had twofold greater odds. These findings suggest that interventions to improve the HIV treatment of IDUs and to reduce their HIV health disparities should be comprehensive, promoting better patient-provider engagement, stable housing, HAART education with regard to illicit drug use, and integration of drug-abuse treatment with HIV primary care.

Knudsen HK; Abraham AJ; Roman PM; Studts JL. Nurse turnover in substance abuse treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network. Journal of Substance Abuse Treatment 40(3): 307-312, 2011. (47 refs.)

Voluntary nurse turnover, which is costly and disrupts patient care, has not been studied as an organizational phenomenon within substance abuse treatment organizations. In this exploratory study, we examined the frequency and correlates of nurse turnover within treatment programs affiliated with the National Drug Abuse Treatment Clinical Trials Network. During face-to-face interviews conducted in 2005-2006, 215 program administrators reported the number of nurses currently employed. Leaders of programs with nursing staff then described the number of nurses who had voluntarily quit in the past year, the degree to which filling vacant nursing positions was difficult, and the average number of days to fill a vacant position. About two thirds of these programs had at least one nurse on staff. In programs with nurses, the average rate of voluntary turnover was 15.0%. Turnover was significantly lower in hospital-based programs and programs offering adolescent treatment but higher in facilities offering residential treatment. Most of the administrators indicated that filling vacant nurse positions was difficult and took more than 2 months to complete. These findings suggest that nurse turnover is a significant issue facing many substance abuse treatment facilities. Efforts to improve retention of the addiction treatment workforce should be expanded to include nursing professionals.

Lafave L; Desportes L; McBride C. Treatment outcomes and perceived benefits: A qualitative and quantitative assessment of a women's substance abuse treatment program. Women & Therapy 32(1): 51-68, 2009. (33 refs.)

This study examines outcomes of a women's substance abuse treatment program based on empowerment, choice, and client/therapist collaboration. The program was assessed through qualitative and quantitative research methods. The article includes extensive quotes from six client interviews as well as data from pre-post surveys of 50 women in the treatment program. Results show that the women felt they benefited from the collaborative treatment approach. Benefits to the women included feeling more empowered and learning to take responsibility for their lives. The importance of taking a broad view of recovery that includes ongoing evaluation of positive changes in various areas of the clients' lives is discussed.

Lee SS; Newman R. Tribute to Peter Lee, pioneer of methadone treatment in Hong Kong. International Journal of Drug Policy 20(2): 99-100, 2009. (1 refs.)

Leontieva L; Dimmock J; Cavallerano M; DeRycke S; Meszaros Z; Carey K et al. Patient and provider attitudes towards monitored naltrexone treatment of alcohol dependence in schizophrenia. American Journal of Drug and Alcohol Abuse 35(5): 273-278, 2009. (20 refs.)

Objective: To describe the attitudes of patients and their mental health providers regarding participation in a controlled trial of directly monitored naltrexone (NTX) treatment for alcohol dependence in schizophrenia. Method: Ninety participants with schizophrenia and their providers were asked to report opinions of treatment with oral NTX or placebo 3 times per week for 12 weeks, motivational counseling (MI), and voucher-based incentives (VBI) for attendance. Results: Seventy-nine percent of participants "liked the study a lot," and 94% reported that it was helpful. Study components rated as helpful by participants were: VBI (95% of participants), meeting with staff 3 times per week (84%), reporting alcohol use (82%), MI (82%), reporting psychiatric symptoms (73%), breath alcohol testing (72%), and study medication (57%). Benefits reported by patients were: feeling better mentally (67%), drinking less (52%), feeling better physically (49%), and stopping drinking (27%). Seventy percent of providers reported that the study was helpful. Benefits noted by providers included: reduced drinking (33%), better treatment adherence (32%), stopping drinking (23%), and reduced psychiatric symptoms (22%). Patient/provider responses agreed on helpfulness with stopping or reducing drinking. Conclusions: Most participants with schizophrenia liked participating in a clinical trial of directly observed naltrexone treatment for alcohol dependence, and found incentives for attendance, frequent staff contact and monitoring of drinking, and motivational counseling to be the most helpful. Most participants reported improvement in mental health and reduced drinking. Mental health providers also reported that the study was helpful, but they did not describe the same degree of benefit as did patients.

Lundgren L; Krull I; Zerden LD; McCarty D. Community-based addiction treatment staff attitudes about the usefulness of evidence-based addiction treatment and CBO organizational linkages to research institutions. Evaluation and Program Planning 34(4): 356-365, 2011. (28 refs.)

This national study of community-based addiction-treatment organizations' (CBOs) implementation of evidence-based practices explored CBO Program Directors' (n = 296) and clinical staff (n = 518) attitudes about the usefulness of science-based addiction treatment. Through multivariable regression modeling, the study identified that identical factors were associated with directors, and staff attitudes about the usefulness of science-based addiction treatment. For both directors and staff working in an organization that was affiliated with a research institution, working in an organization with better internet technology (measured through TCU-ORC scores) and having higher levels of education were all significantly associated with having more positive attitudes regarding science-based addiction treatment. Implications: government policy that promotes the hiring of addiction treatment clinical staff with professional degrees and encourages the development of linkages between addiction treatment researchers and treatment staff may positively impact attitudes and use of evidence-based addiction treatment practices (EBPs) in CBOs.

Luquiens A; Reynaud M; Aubin HJ. Is controlled drinking an acceptable goal in the treatment of alcohol dependence? A survey of French alcohol specialists. Alcohol and Alcoholism 46(5): 586-591, 2011. (26 refs.)

Aim: Assessing acceptance of controlled drinking (CD) among French alcohol specialists. Methods: On-line survey of 547 French alcohol specialists. We searched factors associated with acceptance of CD, and factors that affected the specialists' selection of treatment goal. Criteria for success used by specialists in clinical practice were compared with criteria expected to be used in clinical trials. Results: CD was accepted as a treatment goal by 48.6% of alcohol specialists (n = 105, n = 216), and 61.9% practiced CD for their own patients (n = 130, n = 210). Factors in selecting outcome goals were: patient's choice, perceived self-efficacy, relapse history and severity of dependence. Age, profession and basis of specialists' opinion on CD were associated with acceptance of CD. Conclusion: Half of French alcohol specialists accept CD as a goal. Acceptance was associated with specialists' personal and professional characteristics. The criteria for success specialists use in their clinical practice differ from those they expect to be used in clinical trials.

Madson MB; Loignon AC; Lane C. Training in motivational interviewing: A systematic review. Journal of Substance Abuse Treatment 36(1): 101-109, 2009. (61 refs.)

Motivational interviewing (MI), an evidence-based counseling approach, has received much recognition from a wide variety of health care professionals. Because of the rising interest in motivational interviewing, there is increasing demand for training in this counseling approach. The motivational interviewing training community has answered this call and as a result placed much emphasis on studying the training process. The purpose of this article is to provide a systematic review of the published research on motivational interviewing training. Our goal is to provide a consolidated account of trainings outlining the populations receiving training, methods used, and training outcomes. We also identify which aspects of the (W. R. Miller & T. B. Moyers, 2006) eight stages of learning motivational interviewing each study addressed. Recommendations for advancing the training research are highlighted.

Mael FA; O'Shea PG; Smith MA; Burling AS; Carman KL; Haas A et al. Development of a model and measure of process-oriented quality of care for substance abuse treatment. Journal of Behavioral Health Services & Research 37(1): 4-24, 2010. (30 refs.)

The development of a detailed model of substance-abuse treatment (SAT) staff performance is described. The model describes the key behaviors of SAT staff. Specifically, researchers used the critical incident technique to develop the model, which includes a total of 15 dimensions, nested under four meta-dimensions: providing clinical services, employee citizenship behaviors, providing clinical support, and managerial behavior. Development and validation of a measure based on the model are also described. More than 600 SAT staff members in 51 SAT agencies completed the new measure. Factor analyses supported the measure's hypothesized dimensional structure; high internal consistency reliabilities were observed for all scales; and interrater agreement metrics indicated an acceptable level of within-agency agreement. Moreover, the measure correlated in expected and theoretically consistent ways with measures of job satisfaction and other job-related opinions.

Mallow A. Diversity management in substance abuse organizations: Improving the relationship between the organization and its workforce. Administration in Social Work 34(3): 275-285, 2010. (33 refs.)

Diversity management focuses upon an organization's success in understanding and attending to the needs of its workforce, a workforce that in recent years has become diverse not only in age and gender but also in race, culture, and ethnicity. The interdisciplinary nature of the treatment teams in substance abuse treatment programs lends itself to exploration of diversity management practices to improve the organization's relationship with its workers. The purpose of this paper is to explore diversity management within the therapeutic community offering organizational meta-cultural competency as skill sets needed for the social work manager.

Martino S; Ball S; Nich C; Frankforter TL; Carroll KM. Correspondence of motivational enhancement treatment integrity ratings among therapists, supervisors, and observers. Psychotherapy Research 19(2): 181-193, 2009. (62 refs.)

This study examined the correspondence of treatment integrity ratings (adherence and competence) among community program therapists, supervisors, and observers for therapists who used motivational enhancement therapy (MET) within a National Institute on Drug Abuse Clinical Trials Network protocol. The results suggested there was reasonable agreement between the three groups of raters about the presence or absence of several fundamental MET strategies. Moreover, relative to observers, therapists and supervisors were more positive in their evaluations of the therapists' MET adherence and competence. These findings underscore the need for objective monitoring of therapists' performance when using empirically supported treatments and for adequately training therapists and supervisors to evaluate their treatment implementation in community programs, and are consistent with observations that different perspectives on the therapeutic process are not interchangeable.

Martino S; Ball SA; Nich C; Frankforter TL; Carroll KM. Informal discussions in substance abuse treatment sessions. Journal of Substance Abuse Treatment 36(4): 366-375, 2009

This study evaluated the extent to which counselors initiated informal discussions (i.e., general discussions and self-disclosures about matters unrelated to treatment) with their clients during treatment sessions within two National Institute on Drug Abuse Clinical Trial Network protocols involving adaptations of motivational interviewing (Ml). Sixty counselors across the two protocols had 736 sessions independently rated for counselor treatment fidelity and the occurrence of informal discussions. The results showed that 88% of the counselors initiated informal discussions in their sessions and that most of these discussions involved counselors sharing personal information or experiences they had in common with their clients. The major finding was that counselor training in MI was associated with significantly less informal discussion across sessions. A higher frequency of informal discussion was related to less counselor MI proficiency and less in-session change in client motivation, although unrelated to client program retention and substance use outcomes. The findings suggest that although some informal discussions may help build an alliance between counselors and clients, too much of it may hinder counselors' proficient implementation of MI treatment strategies and the clients' motivational enhancement process.

McKenna B; Thom K; Howard F; Williams V. In search of a national approach to professional supervision for mental health and addiction nurses: The New Zealand experience. Contemporary Nurse 34(2, special issue): 267-276, 2010. (25 refs.)

A competent nursing workforce is crucial for recovery of mental health and addiction service users. Professional supervision is central to facilitating this competency. This article reports on research that scoped the current provision of professional supervision then explores possibilities for developing a standardised national approach to professional supervision for mental health and addiction nurses in New Zealand. The study involved telephone and mail surveys with nurse leaders and current supervisors from district health boards and non-government organisations. The findings indicated that the majority of those canvassed were supportive of a nationally endorsed approach. Standardisation was seen as a means of assisting in the monitoring and quality refinement of the content and provision of professional supervision, and the training of supervisors. It was also recommended that to be successful, a national approach must incorporate partnerships with significant stakeholders in the sector, including service users and Maori.

Melnick G; Ulaszek WR; Lin HJ; Wexler HK. When goals diverge: Staff consensus and the organizational climate. Drug and Alcohol Dependence 103(Supplement 1): S17-S22, 2009. (46 refs.)

A sample of correctional officers and prison substance abuse treatment staff collected by the National Criminal Justice Treatment Practices Survey is used to provide an exploratory Study of an aspect of organizational culture consisting of consensus (agreement) among prison personnel regarding their beliefs about rehabilitation in the presence of conflicting Organizational goals and aspects of the organizational climate important to change. Findings show that among those staff members responding to the Survey. the belief in rehabilitation scale mean score was associated with higher levels of organizational commitment, and interdepartmental coordination. However, an hierarchical linear modeling (HIM) analysis that used an index score derived from the standard deviation for staff consensus regarding these same beliefs about rehabilitation produced a different pattern of results, showing that high levels of consensus were associated with job frustration, cynicism towards the ability of the institution to change, and lower levels of organizational commitment. The authors conclude that, although the sample may not express the beliefs of corrections officers or prison-based treatment staff at large, within the sample, consensus appeared to play a unique role in evaluating the effect of divergent goals on organizational climate as it relates to change, and warrants consideration when considering the effects of organizational climate.

Melnick G; Wexler HK; Chaple M; Cleland CM. Constructive conflict and staff consensus in substance abuse treatment. Journal of Substance Abuse Treatment 36(2): 174-182, 2009. (58 refs.)

Previous studies demonstrated the relationship between consensus among both staff and clients with client engagement in treatment and between client consensus and 1-year treatment outcomes. The present article explores the correlates of staff consensus, defined as the level of agreement among staff as to the importance of treatment activities in their program, using a national sample of 80 residential substance abuse treatment programs. Constructive conflict resolution had the largest effect on consensus. Low client-to-staff ratios, staff education, and staff experience in substance abuse treatment were also significantly related to consensus. Frequency of training, an expected correlate of consensus, was negatively associated with consensus, whereas frequency of supervision was not a significant correlate. The implications of the findings for future research and program improvement are discussed.

Mendelevich VD. Bioethical differences between drug addiction treatment professionals inside and outside the Russian Federation. Harm Reduction Journal 8(e-article 15), 2011. (31 refs.)

This article provides an overview of a sociological study of the views of 338 drug addiction treatment professionals. A comparison is drawn between the bioethical approaches of Russian and foreign experts from 18 countries. It is concluded that the bioethical priorities of Russian and foreign experts differ significantly. Differences involve attitudes toward confidentiality, informed consent, compulsory treatment, opioid agonist therapy, mandatory testing of students for psychoactive substances, the prevention of mental patients from having children, harm reduction programs (needle and syringe exchange), euthanasia, and abortion. It is proposed that the cardinal dissimilarity between models for providing drug treatment in the Russian Federation versus the majority of the countries of the world stems from differing bioethical attitudes among drug addiction treatment experts.

Miles M; Francis K; Chapman Y. Challenges for midwives: Pregnant women and illicit drug use. Australian Journal of Advanced Nursing 28(1): 83-90, 2010. (45 refs.)

Objective: The purpose of the paper is to introduce illicit drug use as a societal problem and describes the response of the Australian Government. Specifically the paper examines the use of illicit drugs by pregnant women and the role of midwives in supporting these women throughout pregnancy and birth. Setting: Maternity services, specifically antenatal care clinics. Conclusion: In Australia the rate of pregnant women who use illicit drugs is escalating. These pregnancies are high obstetric risk with potential for harm to both the mother and the baby. Pregnancy however is seen as 'window of opportunity'; a time to provide education, choices and support. The literature describes that for health professionals working with pregnant women who are illicit drug users is challenging and for some health professionals their interaction can be negative. Australia advocates harm minimisation and encourages harm reduction strategies. Midwives are in a position to implement these strategies within the maternity setting. Further research is recommended as well as professional development programs for midwives to upgrade knowledge and cultivate engagement skills to enable appropriate and positive interaction with pregnant women who use illicit drugs.

Miller WR; Rose GS. Toward a theory of motivational interviewing. American Psychologist 64(6): 527-537, 2009. (93 refs.)

The widely disseminated clinical method of motivational interviewing (MI) arose through a convergence of science and practice. Beyond a large base of clinical trials, advances have been made toward "looking under the hood" of MI to understand the underlying mechanisms by which it affects behavior change. Such specification of outcome-relevant aspects of practice is vital to theory development and can inform both treatment delivery and clinical training. An emergent theory of MI is proposed that emphasizes two specific active components: a relational component focused on empathy and the interpersonal spirit of MI, and a technical component involving the differential evocation and reinforcement of client change talk. A resulting causal chain model links therapist training, therapist and client responses during treatment sessions, and posttreatment outcomes.

Moore D. 'Workers', 'clients' and the struggle over needs: Understanding encounters between service providers and injecting drug users in an Australian city. Social Science & Medicine 68(6): 1161-1168, 2009. (37 refs.)

A feature of contemporary Western, neo-liberal democracies is the frequent interaction between representatives of health and social services and the members of stigmatised and 'unruly' populations, such as injecting drug users. Previous research on drugs has tended to ignore the power relations and cultural dynamics at work in these encounters, and the ways in which they are framed by the wider neo-liberal context. Drawing on an ethnography of street-based heroin use in Melbourne, Australia's second largest city, I show how the discourses of both service providers and injecting drug users draw on wider neo-liberal values of independence, autonomy, rationality and responsibility. Service providers negotiate a framework of needs interpretation that creates and reproduces professional identities, and maintains boundaries between 'workers' and 'clients'. It also includes tensions around the definition of injecting drug users as 'chaotic' (i.e., failed neo-liberal) subjects, and slippage between service philosophies that emphasise a social model of health and forms of service delivery that emphasise the production of responsibilised subjects. For their part, street-based injectors construct an alternative framework of needs interpretation that emphasises their self-reliance, autonomy and independence, attributes and capacities largely denied them in service-provider discourse. In encounters with service providers, street-based injectors respond in various ways that include elements of resistance, strategic accommodation and the incorporation of therapeutic discourse. I conclude by considering the implications of my analysis for the future development of drug policy and practice.

Nabitz U; Jansen P; van der Voet S; van den Brink W. Psychosocial work conditions and work stress in an innovating addiction treatment centre. Consequences for the EFQM Excellence Model. Total Quality Management & Business Excellence 20(3): 267-281, 2009. (30 refs.)

In the Job Demand Control Model (JDCM) and the EFQM Excellence Model, psychosocial work conditions are regarded as critical factors for the functioning of the personnel and the organisation. In order to gain insight into the role of work conditions for the development of work strain and well-being, an empirical study was conducted in an innovating addiction treatment centre in Amsterdam, the Netherlands. The Work Stress Monitor on Mental Health (WSMMH) was used as a measure of the JDCM. A cohort of 209 employees of an addiction treatment centre, in which a far-reaching innovation programme was carried out, participated in this study. With the exception of physical demands, job demands, were high, whereas job controls and the organisational supports were low. Seven out of the 18 work condition scales significantly predicted work strain and well-being. Age and educational level were positive related to well-being. Compared with other health care sectors, work in this addiction treatment centre can be characterised as high-demand low-control and thus as a high strain job. Seven important predictors for this undesirable situation were identified. These predictors can be translated into criteria for the EFQM Excellence Model and can be used to enhance the overall quality of addiction treatment services.

Novotna G; Urbanoski KA; Rush BR. Client-centered design of residential addiction and mental health care facilities: Staff perceptions of their work environment. Qualitative Health Research 21: 11, 2011. (30 refs.)

In this article we discuss the findings from a series of focus groups conducted as part of a 3-year, mixed-method evaluation of clinical programs in a large mental health and substance use treatment facility in Canada. We examined the perceptions of clinical personnel on the physical design of new treatment units and the impact on service delivery and the work environment. The new physical design appeared to support client recovery and reduce stigma; however, it brought certain challenges. Participants reported a compromised ability to monitor clients, a lack of designated therapeutic spaces, and insufficient workspace for staff. They also thought that physical design positively facilitated communication and therapeutic relationships among clinicians and clients, and increased team cohesion. We suggest that, from these findings, new avenues for research on achieving the important balance between client and staff needs in health facility design can be explored.

Nygaard P; Saltz RF. Communication between researchers and practitioners: Findings from a qualitative evaluation of a large-scale college intervention. Substance Use & Misuse 45(1/2): 77-97, 2010. (16 refs.)

Many community-based intervention studies experience problems with collaboration between researchers and practitioners. A preferred strategy appears to be to form community coalitions to carry out the proposed interventions in the community, but doing so risks shifting the focus from intervention objectives to coalition process. As a by-product, coalitions often lack understanding of the project goals and are not given specific instructions on how to implement the intervention. In contrast to conventional wisdom, the Safer California Universities study implemented a very directive approach in collaboration with local liaisons on the participating campuses, even though this approach is seen to risk cooperation or commitment from collaborators. This paper reports on the findings of a qualitative study based on interviews with campus liaisons of how the directive approach was perceived on the participating campuses. Findings indicate that the strategy was successful in terms of "getting things done" but could have been improved in terms of liaison involvement in selling objectives, and in finding the optimal level of specificity.

Okoli CTC; Greaves L; Bottorff JL; Marcellus LM. Health care providers' engagement in smoking cessation with pregnant smokers. (review). Journal of Obstetric, Gynecologic and Neonatal Nursing 39(1): 64-77, 2010. (56 refs.)

Objective: To review how health care providers' (HCPs) engage in smoking cessation (SC) with pregnant smokers, and to examine the effect of system-level approaches and training initiatives to promote SC provision by HCPs. Data Sources A comprehensive search of the CINAHL, COCHRANE Library, EMBASE, ERIC, MEDLINE, PsycINFO, and SIGLE databases was conducted. Study Selection: Selected studies assessed the behaviors of HCPs working among pregnant/postpartum girls and women, employed a quantitative approach, and had clearly defined behavioral outcomes of HCPs' delivery of SC to pregnant smokers. Data Extraction: A total of 988 studies were obtained from the literature search, of which 28 publications met the inclusion criteria. The data extracted from the articles are presented under the following areas: how HCPs are engaging pregnant smokers and approaches to enhancing SC by HCP with pregnant smokers. Data Synthesis: Although more than 50% of HCPs are likely to ask women about their smoking status and advise pregnant smokers to quit, fewer than 50% either assess readiness to change, assist in smoking cessation, or arrange for follow-up appointments/referrals. Important provider-specific, patient-specific, and system/organizational barriers were found to hinder the provision of SC by HCP. Several system-level and training approaches to enhancing HCP's engagement in SC with pregnant smokers show merit. Conclusions: Few HCPs working with pregnant women use all the components of the Agency for Healthcare Research and Quality clinical guidelines. However, system-level and training approaches are effective ways to enhance HCP's engagement in SC; although, the effects of such initiatives may not be sustained. Factors such as the gender of the provider, geographical location, and the use of women-centered treatment approaches could be further examined in relation to provision of SC by HCPs among pregnant smokers.

Olmstead T; Carroll KM; Canning-Ball M; Martino S. Cost and cost-effectiveness of three strategies for training clinicians in motivational interviewing. Drug and Alcohol Dependence 116(1-3): 195-202, 2011. (33 refs.)

Objective: To evaluate the cost and cost-effectiveness of three strategies for teaching community program clinicians motivational interviewing (MI): self-study (SS), expert-led (EX), and train-the-trainer (TT). Methods: This economic analysis was conducted as part of a three-arm clinician training trial comprising 12 community treatment programs randomly assigned to the three conditions (n = 92 clinician participants). EX and IT conditions used skill-building workshops and three monthly supervision sessions. SS provided clinicians MI training materials only. The primary outcome measure was the number of clinicians meeting MI performance standards at 12-week follow-up. Unit costs were obtained via surveys administered at the 12 participating programs. Resource utilizations and clinician outcomes were obtained from the training trial. Costs and outcomes were normalized to account for differing numbers of clinicians across programs and conditions. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were used to evaluate the relative cost-effectiveness of the three training strategies. Results: SS is likely to be the most cost-effective training strategy if the threshold value to decision makers of an additional clinician meeting MI performance standards at 12-week follow-up is less than approximately $2870, and EX is likely to be the most cost-effective strategy when the threshold value is greater than approximately $2870. Conclusions: This study provides accurate estimates of the economic costs and relative cost-effectiveness of three different strategies for training community program clinicians in motivational interviewing and should be of interest to decision makers seeking to implement empirically supported addiction treatments with scarce resources.

Palmer RS; Murphy MK; Piselli A; Ball SA. Substance user treatment dropout from client and clinician perspectives: A pilot study. Substance Use & Misuse 44(7): 1021-1038, 2009. (51 refs.)

Reasons for premature termination of outpatient substance user treatment were evaluated from client and clinician perspectives using qualitative (focus groups) and quanlitative (survey) methods in a pilot study (N = 44). The sample consisted of clients (it = 22), the majority of whom were male (73%) and African American (50%) or Caucasian (41%). The sample of clinicians (n = 22) were predominantly female (64%), and Caucasian (52%) or African American (24%). The most frequently endorsed reasons for leaving treatment were related to individual rather than program characteristics with heavy drug or alcohol use, transportation or financial problems, and ambivalence about abstinence being highly rated by both clinicians and clients. Survey results indicated that clinicians more frequently attributed treatment dropout to individual- or client-level factors than did clients. Focus group ratings indicated that clinicians felt client motivation and staff connection issues were primary reasons for dropout, whereas clients indicated social support and staff connection issues. The findings suggest that the development of early therapeutic alliance and active problem solving of potential barriers to treatment attendance may influence treatment retention.

Petry NM; Alessi SM; Ledgerwood DM; Sierra S. Psychometric properties of the Contingency Management Competence Scale. Drug and Alcohol Dependence 109(1-3): 167-174, 2010. (40 refs.)

Contingency management (CM) is an evidence-based treatment, and clinicians are beginning to implement this intervention in practice. However, little research exists on methods for assuring appropriate implementation of CM. This study describes the development and psychometric properties of the 12-item CM Competence Scale (CMCS). Thirty-five therapists from nine community-based clinics participated; following a training period, a randomized trial evaluated the efficacy of CM in cocaine abusing patients. Analyses of the CMCS are based on ratings from 1613 audiotapes of therapist interactions with 78 patients enrolled in the training phase and 103 patients in the randomized phase. Inter-rater reliability from 11 raters and internal consistency of items on the CMCS was good to excellent. Items loaded onto two factors: one contained items specific to discussions of the outcomes of urine testing and reinforcement, and the other contained general items related to use of praise, communication of confidence, empathy, skillfulness, and maintaining session structure, as well as discussions of self-reports of drug use when they occurred. During the training phase in CM delivery, scores on the CMCS rose significantly between earlier and later training sessions, and during the randomized phase, CM sessions were rated more highly than non-CM sessions. Scores on the subscale assessing general items were significantly correlated with indices of the therapeutic alliance and predictive of durations of cocaine abstinence achieved. These data suggest that the CMCS is reliable and valid in assessing delivery of CM and that competence in CM delivery is associated with improved patient outcomes.

Pinto RM; Yu G; Spector AY; Gorroochurn P; McCarty D. Substance abuse treatment providers' involvement in research is associated with willingness to use findings in practice. Journal of Substance Abuse Treatment 39(2): 188-194, 2010. (32 refs.)

Using a national sample (n = 571) of substance abuse treatment providers affiliated with the Clinical Trials Network, we examined the contribution of several factors -- demographic, attitudes, and involvement in research -- toward providers' willingness to use research findings in practice. The sample included medical staff, social workers, psychologists, and counselors. Using a multiple linear regression model, we examined the impact of involvement in research and willingness to use research findings in practice. Providers involved in research were more willing to use findings in practice (p < .001). Latino/Latinas were less willing (p < .05). Providers with favorable attitudes toward evidence-based practices and whose agencies supported professional growth were more willing to use findings (p < .01). Involvement in research may enhance providers' willingness to use findings in practice and improve quality of services. Results underscore the need for providing opportunities for all providers to engage in substance abuse treatment research, particularly racial/ethnic minority providers.

Roche AM. New horizons in AOD workforce development. Drugs: Education, Prevention and Policy 16(3): 193-204, 2009. (29 refs.)

The papers in this series are presented by Australia's National Research Centre on Workforce development, or as it is formally known as the National Centre for Education and Training on Addiction (NCETA), at Flinders University in Australia. NCETA is recognized nationally and internationally as a research centre that works as a catalyst for change in the alcohol and other drugs (AOD) sector. NCETA is one of the three national research Centres in Australia funded under the National Drug Strategy, and the only Centre briefed to specifically address issues related to workforce development. In this guise, the Centre's mission is to advance the capacity of human services organizations and workers to respond to alcohol and other drug related problems. NCETA's role is not restricted to the area of workforce development. The Centre also undertakes an important programme of work in relation to the workplace, law enforcement, complex data analyses on a range of topics and has an innovative programme of social research on issues such as young people and alcohol. The focus of attention selected for this issue however provides a sample of our work in the area of workforce development.

Saarnio P. Big five personality traits and interpersonal functioning in female and male substance abuse therapists. Substance Use & Misuse 45(10): 1463-1473, 2010. (28 refs.)

The purpose of the study was to investigate whether gender differences occur in personality traits or interpersonal functioning among substance abuse therapists in the same way as they do on population level. The subjects (N = 162) were therapists in Finnish inpatient treatment institutions. Female therapists (N = 119) scored significantly higher than male therapists (N = 43) on two personality factors: friendliness and openness to experiences. Women were also better than men in interpersonal functioning; they scored higher on all dimensions of it, namely, empathy, genuineness, respect for client, and concreteness.

Schoenwald SK; Hoagwood KE; Atkins MS; Evans ME; Ringeisen H. Workforce development and the organization of work: The science we need. Administration and Policy in Mental Health and Mental Health Services Research 37(1-2, special issue): 71-80, 2010. (40 refs.)

The industrialization of health care, underway for several decades, offers instructive guidance and models for speeding access of children and families to clinically and cost effective preventive, treatment, and palliative interventions. This industrialization --i.e., the systematized production of goods or services in large-scale enterprises --has the potential to increase the value and effects of care for consumers, providers, and payers (Hayes and Gregg in Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. Academic Press, San Diego, 2001), and to generate efficiencies in care delivery, in part because workforce responsibilities become more functional and differentiated such that individuals with diverse educational and professional backgrounds can effectively execute substantive clinical roles (Rees in Clin Exp Dermatol, 33, 39-393, 2008). To date, however, the models suggested by this industrialization have not been applied to children's mental health services. A combination of policy, regulatory, fiscal, systemic, and organizational changes will be needed to fully penetrate the mental health and substance abuse service sectors. In addition, problems with the availability, preparation, functioning, and status of the mental health workforce decried for over a decade will need to be addressed if consumers and payers are to gain access to effective interventions irrespective of geographic location, ethnic background, or financial status. This paper suggests that critical knowledge gaps exist regarding (a) the knowledge, skills, and competencies of a workforce prepared to deliver effective interventions; (b) the efficient and effective organization of work; and (c) the development and replication of effective workforce training and support strategies to sustain effective services. Three sets of questions are identified for which evidence-based answers are needed. Suggestions are provided to inform the development of a scientific agenda to answer these questions.

Schult TM; Awosika ER; Hodgson MJ; Dyrenforth S. Disparities in health behaviors and chronic conditions in health care providers in the Veterans Health Administration. Journal of Occupational and Environmental Medicine 53(10): 1134-1145, 2011. (31 refs.)

Objective: To determine baseline prevalence of health behaviors and chronic health conditions in Veterans Health Administration (VHA) employees and highlight disparities by occupation group. Methods: There were 29,834 responses to the survey. Age-standardized prevalence estimates for VHA employees were compared to national estimates from BRFSS surveys. The VHA estimates were analyzed for physicians and dentists; physician assistants and nurse practitioners; registered nurses; licensed practical nurses and nursing assistants; other clinical; nonclinical; and wage grade staff. Multilevel regression explored the effect of worksite. Results: The VHA employees have higher rates of unhealthy behaviors and chronic health conditions than US adults, except for smoking. Results illustrated significant disparities between occupation groups by demographics and variability by worksite. Conclusions: Veterans Health Administration's population appears less healthy than the US general population. Disparities between occupation groups support the establishment of targeted health promotion programs, with attention paid to differences in local culture.

Siddiqui N; Astone-Twerell J; Hernitche T. Staff perspectives on modified therapeutic community services for homeless dually diagnosed clients: An exploratory pilot study. Journal of Psychoactive Drugs 41(4): 355-361, 2009. (26 refs.)

The modified therapeutic community (MTC) is one treatment modality developed to meet the needs of the homeless dually diagnosed population. While studies have shown the effectiveness of the MTC, little is known regarding staff perspectives of this modality. Using data from in-depth qualitative interviews, this study examines key staff perspectives on treatment services offered at an MTC in New York for homeless, mentally ill substance abusers. Many staff members indicated that the services provided are innovative, state of the art, and comprehensive as compared to other programs that specifically treat only one need. The most beneficial aspects of the MTC modality noted were the number of social workers available and the introduction of art therapy groups. The MTC modality also fostered increases in communication and collaboration between staff to introduce more specialized clinical groups not outlined in MTC guidelines to better meet the needs of clients.

Simmons VN; Litvin EB; Patel RD; Jacobsen PB; McCaffrey JC; Bepler G et al. Patient-provider communication and perspectives on smoking cessation and relapse in the oncology setting. Patient Education and Counseling 77(3, Special Issue): 398-403, 2009. (21 refs.)

Objective: To fill a gap in research by examining cancer patient-provider communication regarding tobacco use and patients' perspectives regarding their experiences with smoking cessation and relapse. Methods: In-depth interviews were conducted with 20 lung and head and neck cancer patients and I I health care providers. Results: Qualitative analyses revealed that cancer patients express high levels of motivation to quit smoking; however, patients do not ask providers for assistance with quitting and maintaining abstinence and relapsed patients are reluctant to disclose smoking behavior due to stigma and guilt. Health care providers vary in the advice and type of assistance they supply, and their awareness and sensitivity to relapsed patients' feelings. Whereas providers emphasized long-term risks of continued smoking in their interactions with patients and recommendations for intervention content, patients expressed a preference for a balance between risks and benefits. Conclusion: Findings underscore the need for increased awareness, emphasis, and communication about the immediate risks of continued smoking and the benefits of continued abstinence specifically for cancer patients. Practice implications: Our findings demonstrate the potential to affect cancer outcomes by improved training in conducting smoking cessation and relapse-prevention interventions. Additional training could be given to health care providers to increase adherence to clinical practice guidelines (5 A's), to learn ways to enhance patients' motivation to maintain abstinence, and to deliver smoking messages in a non-threatening manner.

Smith DC; Hall JA; Jang MJ; Arndt S. Therapist adherence to a motivational-interviewing intervention improves treatment entry for substance-misusing adolescents with low problem perception. Journal of Studies on Alcohol and Drugs 70(1): 101-105, 2009. (31 refs.)

Objective: This study evaluated whether adherence to the Strengths-Oriented Referral for Teens (SORT) model, a motivational interviewing (MI)-consistent intervention addressing ambivalence about attending treatment, positively predicted adolescents' initial-session attendance. Method: Therapist adherence was rated in 54 audiotaped SORT sessions by coders who were blind to treatment-entry status. Higher adherence scores reflected greater use of MI and solution-focused language, discussion of client strengths, and dialogue with families on treatment need and options. Results: Therapist adherence during adolescent segments interacted with adolescent problem perception. Predicted probabilities of attending initial sessions increased for low-problem-perception adolescents at increasingly higher therapist adherence. Conclusions: Although replication studies are needed, the SORT model of providing MI-consistent debriefing following initial assessments appears to be a promising approach for increasing treatment entry initial support for the treatment-matching hypothesis was found for substance-misusing adolescents contemplating treatment entry

Stanhope V; Henwood BF; Padgett DK. Understanding service disengagement from the perspective of case managers. Psychiatric Services 60(4): 459-464, 2009. (32 refs.)

Objective: Disengagement from services by persons experiencing homelessness and co-occurring disorders challenges the mental health system and the frontline providers who build clinical relationships that end prematurely. This qualitative study explored how case managers understand and respond to disengagement. Methods: This study was conducted at four programs serving persons with co-occurring disorders experiencing homelessness. The qualitative design used a case study approach based on in-depth interviews with 18 case managers about 29 cases of disengagement. The study compared their accounts with predisengagement interviews when available and the postdeparture residential status of consumers. Themes were derived by independent coding and consensus. Results: Case managers attributed disengagement primarily to substance relapse and a preference for alternative living arrangements. The following themes emerged: seeing disengagement as part of their work, believing disengagement to be poor decision making on the part of the consumer, and coping with the revolving-door syndrome. The majority of consumers experienced homelessness after disengagement. Conclusion: The study illustrated the challenge of building hope-instilling relationships with consumers when faced with the reality of frequent disengagement. In an era of recovery-oriented services and consumer choice, case managers need support when faced with consumer decisions to leave treatment settings. Greater program flexibility may also help to reduce disengagement.

Strike C; Rufo C. Embarrassing, degrading, or beneficial: Patient and staff perspectives on urine drug testing in methadone maintenance treatment18. Journal of Substance Use 15(5): 303-312, 2010. (18 refs.)

Urine drug testing is a routine, but debated and contentious procedure in methadone maintenance treatment (MMT). Largely overlooked in the debate are the perspectives of patients and clinical staff about this procedure. Using semi-structured interviews (n = 64) with MMT patients and clinical staff at four programmes, we explore their attitudes and perceived implications for treatment. We documented varied urinalysis practices by site and with considerable disagreement regarding its emotional impact and therapeutic value. Among patients, comments about urine drug testing varied from degrading to ambivalence to acceptance as a necessary component of treatment. Staff members who supported urinalysis and described it as beneficial stated that it provided a point of entry into patients' lives and helped to identify possible barriers to recovery. Others believed urinalysis impeded the development and maintenance of an effective therapeutic alliance. Lack of strong empirical evidence demonstrating improved patient outcome related to urine drug testing suggests that this procedure should be determined based on individual patient goals.

Stull LG; McGrew JH; Salyers MP. Staff and consumer perspectives on defining treatment success and failure in assertive community treatment. Psychiatric Services 61(9): 929-932, 2010. (15 refs.)

Objective: Although assertive community treatment (ACT) has been consistently recognized as effective, there has been little research as to what constitutes success in ACT. The purpose of this study was to understand how ACT consumers and staff define treatment success and failure and to examine whether definitions varied between staff and consumers. Methods: Investigators conducted semistructured interviews with 25 staff and 23 consumers from four ACT teams. Results: Across perspectives, success and failure were most clearly related to consumer factors. Other themes included having basic needs met, being socially involved, and taking medications. Reduced hospitalizations were mentioned infrequently. Consumers were more likely than staff to identify the level or type of treatment as defining success and failure, whereas staff were more likely than consumers to discuss substance abuse when defining failure and improved symptoms when defining success. Conclusions: Success in ACT should be viewed more broadly than reduced hospitalizations and include domains such as social involvement.

Thompson M; Robertson J; Clough A. A review of the barriers preventing Indigenous Health Workers delivering tobacco interventions to their communities. (review). Australian and New Zealand Journal of Public Health 35(1): 47-53, 2011. (25 refs.)

Objective: To review available literature addressing the issue of whether smoking status of Indigenous Health Workers (IHWs) impedes provision of health information about smoking tobacco to their communities. Method: Databases were searched for publications that examined IHWs' smoking status or quit support programs for IHWs. Studies were categorised as reviews and commentaries, intervention studies or descriptive research. Results: Fourteen studies met inclusion criteria. Overall, the literature suggests that IHWs' smoking status is a barrier. However, the poor quality of most studies weakens the evidence for this conclusion. The issue of IHWs smoking status as a barrier is peripheral to all but two of the studies. Literature cited and reviewed was often not exhaustive and relied on only a few preceding empirical studies. Most studies were unclear about whether IHWs' views were reported as distinct from views of health staff in general. Conclusions and implications: The recent COAG investment to Tackling Smoking is an important contribution to Closing the Gap in the health of Indigenous Australians. However, there remain potential barriers faced by IHWs that may undermine efforts to reduce Indigenous smoking. Overcoming these barriers and assisting IHWs to quit smoking may provide an opportunity to address high rates of smoking in Indigenous communities. Further research is required with a balance between descriptive research to assess the issue and intervention research to address it.

Tracy K; Brown LS; Kritz S; Alderson D; Robinson J; Bini EJ et al. Substance abuse treatment clinician opinions and infectious disease service delivery. Journal of Addictive Diseases 28(1): 8-12, 2009. (8 refs.)

Substance abuse treatment programs are an important platform for delivery of services for infectious diseases associated with drug and alcohol use. However, important components of infectious disease care are not universally provided. Clinician training often focuses on information about infectious diseases and less attention is paid to provider opinions and attitudes that may be barriers to providing infectious diseases services. In a national multi-site trial conducted by the National Drug Abuse Treatment Clinical Trials Network (CTN), we investigated the relationship between clinician opinions and the delivery of services for human immunodeficiency virus, hepatitis C virus, and sexually transmitted infections in substance abuse treatment settings. Survey data were collected from 1,723 clinicians at 269 CTN treatment programs. Clinician opinion was found to be significantly related to infectious disease service delivery. Implications for training are discussed.

Trujols J; Sinol N; Iraurgi I; Batlle F; Guardia J; de los Cobos JP. Patient and clinician's ratings of improvement in methadone-maintained patients: Differing perspectives? Harm Reduction Journal 8: article 23, 2011. (43 refs.)

Background: In the last few years there seems to be an emerging interest for including the patients' perspective in assessing methadone maintenance treatment (MMT), with treatment satisfaction surveys being the most commonly-used method of incorporating this point of view. The present study considers the perspective of patients on MMT when assessing the outcomes of this treatment, acknowledging the validity of this approach as an indicator. The primary aim of this study is to evaluate the concordance between improvement assessment performed by two members of the clinical staff (a psychiatrist and a nurse) and assessment carried out by MMT patients themselves. Method: Patients (n = 110) and their respective psychiatrist (n = 5) and nurse (n = 1) completed a scale for assessing how the patient's condition had changed from the beginning of MMT, using the Patient Global Impression of Improvement scale (PGI-I) and the Clinical Global Impression of Improvement scale (CGI-I), respectively. Results: The global improvement assessed by patients showed weak concordance with the assessments made by nurses (Quadratic-weighted kappa = 0.13, p > 0.05) and by psychiatrists (Quadratic-weighted kappa = 0.19, p = 0.0086), although in the latter, concordance was statistically significant. The percentage of improved patients was significantly higher in the case of the assessments made by patients, compared with those made by nurses (90.9% vs. 80%, Z-statistic = 2.10, p = 0.0354) and by psychiatrists (90.9% vs. 50%, Z-statistic = 6.48, p < 0.0001). Conclusions: MMT patients' perception of improvement shows low concordance with the clinical staff's perspective. Assessment of MMT effectiveness should also focus on patient's evaluation of the outcomes or changes achieved, thus including indicators based on the patient's experiences, provided that MMT aim is to be more patient centred and to cover different needs of patients themselves.

Tucker JA; Foushee HR; Simpson CA. Increasing the appeal and utilization of services for alcohol and drug problems: What consumers and their social networks prefer. International Journal of Drug Policy 20(1): 76-84, 2009. (36 refs.)

Background: A large gap exists in the United States between population need and the utilization of treatment services for substance-related problems. Surveying consumer preferences may provide valuable information for developing more attractive services with greater reach and impact on population health. Methods: A state-level telephone survey using random digit dialling sampling methods assessed preferences for available professional, mutual help, and lay resources, as well as innovative computerized and self-help resources that enhance anonymity (N=439 households in Alabama). Results: Respondents preferred help that involved personal contact compared to computerized help or self-help, but were indifferent whether personalized help was dispensed by professional or lay providers. Attractive service features included lower cost, insurance coverage, confidentiality, rapid and convenient appointments, and addressing functional problems and risks of substance misuse. Respondents in households with a member who misused substances rated services more negatively, especially if services had been used. Conclusion: The findings highlight the utility of viewing substance misusers and their social networks as consumers, and the implications for improving the system of care and for designing and marketing services that are responsive to user preferences are discussed.

Vandermause RK; Townsend RP. Teaching thoughtful practice: Narrative pedagogy in addictions education. Nurse Education Today 30(5): 428-434, 2010. (37 refs.)

Preparing practitioners for this rapidly changing and demanding health care environment is challenging. A surge in knowledge development and scientific advancement has placed a priority on technical skill and a focus on content driven educational processes that prepare students for evidence-based practice. However, the most difficult health care scenarios require thinking-in-action and thoughtfulness as well as didactic knowledge. It is our contention that interpretive educational methods, like narrative pedagogy, will promote judgment-based practice that includes use of evidence and delivery of thoughtful care. In this article, we describe and interpret a narrative approach to addictions content and teaching thoughtful practice. We present our pedagogical process, including observations and field notes, to show how interpretive pedagogies can be introduced into nursing curricula. By presenting this process, the reader is invited to consider interpretive methods as a way to inspire and habituate thoughtful practice and judgment-based care.

VanDerNagel J; Kiewik M; Buitelaar J; DeJong C. Staff perspectives of substance use and misuse among adults with intellectual disabilities enrolled in Dutch disability services. Journal of Policy and Practice in Intellectual Disabilities 8(3): 143-149, 2011. (15 refs.)

Although the use of psychoactive substances seems to be a growing problem among clients of intellectual disability services (IDS) in the Netherlands, rates of such substance use are unknown, and it is unclear how the services deal with substance-related problems. This study explored the perspectives of staff with respect to the occurrence of substance use and abuse, as well as users' profiles, and service organization policies regarding substance use. A semi-structured questionnaire asked staff to comment on lifetime, current, and problematic substance use among their clients, provide illustrative case reports, and describe policies within their service regarding substance-related problems. Data from 39 IDS were included. Estimations of occurrence of substance use varied greatly across services. Alcohol was reported to be used most often but at lower rates than reported in the general population. Cannabis and other drugs were reported to be used relatively often when compared with the rates noted in the general population. Case reports on 86 substance users were analyzed, and subgroups of users were identified, including younger clients who used both cannabis and alcohol, and older clients with mild ID who used only alcohol. Psychiatric comorbidity and lack of daytime activities were highly prevalent among users. Of the interventions the services reported using to address abuse, psychosocial and restrictive measures were rated as most effective and collaboration with addiction facilities and rewarding abstinence as least effective. Most services reported to have inadequate expertise with substance use. According to respondents, users with both borderline and mild ID used substances, but there were different patterns of use across age groups and level of ID. Respondents noted that substance users face a number of psychosocial problems but that they were poorly equipped to meet the users' needs and to affect functional policies. The authors concluded that the low effectiveness of mainstream addiction treatment or consultation suggests that there is a need for more cross-system collaboration to address this problem.

Vederhus JK; Kristensen O; Laudet A; Clausen T. Attitudes towards 12-step groups and referral practices in a 12-step naive treatment culture: A survey of addiction professionals in Norway. BMC Health Services Research 9: e-147, 2009. (31 refs.)

Background: Addressing substance use disorders effectively requires a long-term approach. Substance abuse treatment is typically of short duration; referring patients to Twelve Step based self-help groups (TSGs) - e. g. Narcotics Anonymous, represents a promising complementary recovery resource. Clinicians' attitudes and referral practices towards the TSGs have mainly been studied in countries with high integration of the 12-step philosophy in their substance abuse services and where the TSGs are widely available, such as the US. In Norway, there are currently 294 weekly TSG meetings (6 per 100,000 inhabitants). This study describes clinicians' attitudes and referral practices to TSGs in Norway where health authorities seek to promote self-help participation, but where the treatment culture is unfamiliar with 12-step fellowships. Methods: Data collected by a self-administered questionnaire, adapted from established US and UK instruments. Information covered the attitudes, knowledge and referral practices towards TSGs among addiction treatment professionals in Norway in mid 2008. Results: The return rate was 79.7% (n = 291). Participants had moderately positive attitude scores towards TSGs, but referral to these groups among Norwegian addiction professionals was low, as was the level of knowledge about TSGs. More than six out of ten did not refer any patients to TSGs in the previous week. Local variation with more referrals to TSGs in the county with the one established 12-step treatment facility was observed. Respondents' integration of the 12-steps in their own treatment work, higher self-efficacy for making a successful referral, and greater TSG knowledge were associated with referring patients. Conclusion: Low referral rates to TSGs point to the need for education and training to raise the awareness and knowledge about it among addiction professionals unfamiliar with these 12-step fellowships. Training should focus on the usefulness of these groups for all types of treatment models regardless of therapeutic orientation. Increased knowledge is expected to lead to higher referral rates, which in turn would maximize the likelihood of positive long-term patient outcomes.

Vederhus JK; Laudet A; Kristensen O; Clausen T. Obstacles to 12-step group participation as seen by addiction professionals: Comparing Norway to the United States. Journal of Substance Abuse Treatment 39(3): 210-217, 2010. (39 refs.)

Twelve-step groups (TSGs) are a valuable recovery resource for substance-dependent individuals. However, some aspects of these fellowships are controversial and may limit clinician referrals. This study describes attitude- and knowledge-based barriers to TSG participation as seen by addiction professionals in Norway, a treatment culture in which less than 5% of programs use the 12-step philosophy, and compares the findings with those of a similar study in the United States. Data were collected in Norway in mid-2008 using a self-administered questionnaire, and the U.S. sample was obtained from historical data. The Norwegian professionals (n = 291) considered the religious aspects of TSGs a considerable obstacle to participation, whereas the U.S. providers (n 7 100) did not. Treatment providers unfamiliar with the 12-step philosophy need to be better informed of TSGs' "higher power" concept to educate patients and maximize the utilization of TSGs.

Villalbi JR; Gual A. Policies for the prevention of addictive substance use and the responsibility of professionals. (Spanish). Adicciones 21(1): 5-8, 2009. (18 refs.)

Professionals treating persons with addictions must work with the individual characteristics of each case. However, collective aspects shape consumption at the population level and also the personal frequency of exposure-which influences the development of dependence. Among factors influencing consumption, some may be modified by regulations or public policies. Most important are those related to substance availability, social acceptability of use, promotion, price, and treatment availability. This editorial discusses actors favouring and opposing the adoption of preventive policies, the contexts in which they are discussed, and the potential role of professionals and their organisations.

Wallace SL; Lee J; Lee SM. Job stress, coping strategies, and burnout among abuse-specific counselors. Journal of Employment Counseling 47(3, special issue): 111-122, 2010. (46 refs.)

The purpose of this study is to investigate whether effective coping strategies play an important role to reduce burnout levels among sexual or substance abuse counselors. The authors examined whether coping strategies mediated or moderated relations between job stress and burnout in a sample of 232 abuse-specific counselors. Results indicated that self-distraction and behavior disengagement coping strategies mediated the relationships between 3 job stress variables (workload, role conflict, and job ambiguity) and burnout. Although venting and humor coping strategies positively moderated the relationship between role ambiguity and burnout, active coping strategies negatively moderated the relationship between workload and burnout.

Wallace L; Turner F. A systematic review of psychometric evaluation of motivational interviewing integrity measures . Journal of Teaching in the Addictions 8(1/2): 84-123, 2009. (56 refs.)

The Motivational Interviewing Skills Code (MISC) has been developed to measure motivational interviewing skill, but a need has been identified for more economical instruments. This study expands on a previous systematic review by Madson and Campbell (2006) and examines the extent to which motivational interviewing integrity measures other than the MISC have been developed and psychometrically tested. Seven studies were reviewed that tested 5 such measures: the Motivational Interviewing Process Code (MIPC), the Motivational Interviewing Supervision and Training Scale (MISTS), the Motivational Interviewing Treatment Integrity Code (MITI), the Behaviour Change Counselling Index (BECCI), and the Video Assessment of Simulated Encounters (VASE). Although these instruments are promising, further psychometric testing is required and current findings should be judged as preliminary. Furthermore, external validity criteria and additional information that would facilitate consumer decision making are lacking. Recommendations for further development and research on these instruments and training studies generally are provided.

Williams EC; Johnson ML; Lapham GT; Caldeiro RM; Chew L; Fletcher GS et al. Strategies to implement alcohol screening and brief intervention in primary care settings: A structured literature review. (review). Psychology of Addictive Behaviors 25(2): 206-214, 2011. (41 refs.)

Although alcohol screening and brief intervention (SBI) reduces drinking in primary care patients with unhealthy alcohol use, incorporating SBI into clinical settings has been challenging. We systematically reviewed the literature on implementation studies of alcohol SBI using a broad conceptual model of implementation, the Consolidated Framework for Implementation Research (CFIR), to identify domains addressed by programs that achieved high rates of screening and/or brief intervention (BI). Seventeen articles from 8 implementation programs were included; studies were conducted in 9 countries and represented 533,903 patients (127,304 patients screened), 2,001 providers, and 1,805 clinics. Rates of SBI varied across articles (2-93% for screening and 0.9-73.1% for BI). Implementation programs described use of 7-25 of the 39 CFIR elements. Most programs used strategies that spanned all 5 domains of the CFIR with varying emphases on particular domains and sub-domains. Comparison of SBI rates was limited by most studies' being conducted by 2 implementation programs and by different outcome measures, scopes, and durations. However, one implementation program reported a high rate of screening relative to other programs (93%) and could be distinguished by its use of strategies that related to the Inner Setting, Outer Setting, and Process of Implementation domains of the CFIR. Future studies could assess whether focusing on Inner Setting, Outer Setting, and Process of Implementation elements of the CFIR during implementation is associated with successful implementation of alcohol screening, as well as which elements may be associated with successful, sustained implementation of BI.

Wisdom JP; Gogel LP. Perspectives on adolescent residential substance abuse treatment: When are adolescents done? Psychiatric Services 61(8): 817-821, 2010. (19 refs.)

Objectives: the study evaluated responses from adolescents in substance abuse treatment, their parents, and treatment staff to the question of what constitutes treatment success. Methods: Semistructured interviews were conducted with 28 adolescents, 30 parents, and 29 staff at three residential substance abuse treatment programs in two states. Data were coded and organized into themes by respondent type. Results: Respondents reported knowing when treatment was no longer needed based on changes in adolescents' substance use, treatment-related and other behaviors, and attitudes and character. A fourth category of responses indicated respondents' ambiguity regarding successful completion of substance abuse treatment. Little concurrence was found among adolescents, parents, and treatment center staff to indicate criteria suggesting that discharge is appropriate. Conclusions: Substance abuse treatment programs and their clients may benefit from ensuring that staff, parents, and adolescents are aware of treatment goals to promote more effective treatment and improve collaboration toward the adolescent's recovery.

Wye P; Bowman J; Wiggers J; Baker A; Knight J; Carr V et al. Total smoking bans in psychiatric inpatient services: A survey of perceived benefits, barriers and support among staff. BMC Public Health 10: 372, 2010. (51 refs.)

Background: The introduction of total smoking bans represents an important step in addressing the smoking and physical health of people with mental illness. Despite evidence indicating the importance of staff support in the successful implementation of smoking bans, limited research has examined levels of staff support prior to the implementation of a ban in psychiatric settings, or factors that are associated with such support. This study aimed to examine the views of psychiatric inpatient hospital staff regarding the perceived benefits of and barriers to implementation of a successful total smoking ban in mental health services. Secondly, to examine the level of support among clinical and non-clinical staff for a total smoking ban. Thirdly, to examine the association between the benefits and barriers perceived by clinicians and their support for a total smoking ban in their unit. Methods: Cross-sectional survey of both clinical and non-clinical staff in a large inpatient psychiatric hospital immediately prior to the implementation of a total smoking ban. Results: Of the 300 staff, 183 (61%) responded. Seventy-three (41%) of total respondents were clinical staff, and 110 (92%) were non-clinical staff. More than two-thirds of staff agreed that a smoking ban would improve their work environment and conditions, help staff to stop smoking and improve patients' physical health. The most prevalent clinician perceived barriers to a successful total smoking ban related to fear of patient aggression (89%) and patient non-compliance (72%). Two thirds (67%) of all staff indicated support for a total smoking ban in mental health facilities generally, and a majority (54%) of clinical staff expressed support for a ban within their unit. Clinical staff who believed a smoking ban would help patients to stop smoking were more likely to support a smoking ban in their unit. Conclusions: There is a clear need to more effectively communicate to staff the evidence that consistently applied smoking bans do not increase patient aggression. There is also a need to communicate the benefits of smoking bans in aiding the delivery of smoking cessation care, and the benefits of both smoking bans and such care in aiding patients to stop smoking.