Targeting Incentives to Influence Practice in Community-based Substance Abuse Treatment

Background: Addiction treatment practices with demonstrated efficacy under ideal conditions have proven difficult to implement in typical community settings. Administrators need effective incentives to help substance abuse treatment counselors use treatment approaches supported by evidence. Common targets of current incentives, however, often reflect different implicit theories about the important influences on counselor behavior. This study translated theories proven to explain health behaviors (see Fishbein, 1995) to the behaviors or practices of frontline treatment counselors. The study tests hypotheses addressing the likely utility of different incentives –- implementation-related vs. motivation-related -- to promote counselors' use of evidence-based treatment approaches.

Methods. The study involves a cross-sectional survey of frontline counselors who provide outpatient substance abuse treatment. The study involved a nested probability sample. First, organizations were randomly selected from those meeting selection criteria based on location, size and type. Of the 70 organizations selected, 57 participated, for an organization-level response rate of 81%. Surveys were distributed in person and by mail to 429 counselors in the organizations and 293 (68%) participated. Treatment approaches were measured with a 30-item scale adapted from the Practitioner Technique Inventory (Ball, et al., 2002). The scale measures the degree to which counselors use treatment techniques supported by evidence as well as techniques associated with a 12-step/disease-based model and other approaches lacking evidence. The survey instrument included measures of: counselor beliefs about substance abuse, attitudes toward evidence-based practice, training exposure, training application, organization policies and other organizational conditions. Multi-level (HLM) regression models were conducted to appropriately address the nested sample while assessing the association of individual and organizational-level factors with treatment approaches (Raudenbush & Bryk, 1992).

Results: Results of multi-level regression models indicate that counselors' beliefs about addiction and attitudes toward evidence-based practice were significantly associated with practice behaviors. Counselors with open attitudes toward evidence-based approaches reported greater use of the approaches. Counselors with negative attitudes toward experts and research and stronger beliefs consistent with a disease concept of addition reported lesser use of practice approaches associated with evidence. Whereas counselors who reported greater application of training content reported greater use of evidence-based approaches, amount of training exposure was not associated with practice approach. Similarly, at the organization level, organizational policy and pressures to use evidence-based approaches were not associated with greater use of the approaches. In general, organizational policies and pressures had less influence on practice approaches than did concrete environmental aids or obstacles. That is, pressures from a supervisor or requirements to use evidence-based approaches had weaker associations with practice than did concrete aids such as sufficient staffing levels and updated equipment.

Implications: Effectively moving evidence-based treatment approaches into community substance abuse treatment settings requires incentives and assistance that are appropriately targeted. Reflecting a theory-based approach addressing both individual and organizational contexts, this study begins to illuminate potentially fruitful incentive targets. Findings suggest that additional training and organizational rules may be ineffective first targets for influencing practice behavior. Incentives might more effectively target counselor attitudes and beliefs as well as concrete resource gaps in community treatment settings.