Monday, September 15, 2014

A Recipe for Success

Roxanne Allen

SMART Recovery Meeting Facilitator

“The research evidence clearly demonstrates that a one-size-fits-all approach to addiction treatment typically is a recipe for failure.” 1

If the one-size-fits-all approach is a recipe for failure, what approach is needed for success?


One of the central messages of the New Recovery Advocacy Movement is the declaration that there are many pathways and styles of long-term recovery from severe alcohol and other drug problems. 2

This concept applies not only to the many choices available for treatment options but also to the many choices now available for peer support. For many years the only options for addiction recovery peer support groups were based on a 12-step, external locus of control approach (AA, NA, GA, etc.)

One of the three mutual-aid groups featured at the recent ONDCP (Office of National Drug Control Policy) webinar, “Expanding Opportunities for Recovery: An Introduction to Three Secular, Abstinence-Based Mutual Aid Pathways,” was SMART Recovery®.

Self-Management and Recovery Training

Now in its 20th year, SMART Recovery (Self-Management And Recovery Training) is a science-based, international, self-empowering addiction recovery support group. Headquartered in the U.S., SMART Recovery exists to help people with all types of addiction and addictive behaviors including drug abuse and addiction, alcohol abuse, and addiction to other substances and activities.

SMART Recovery participants learn tools for recovery based on the latest scientific research. There are now 669 weekly face-to-face meetings held throughout the U.S. and an additional 630 elsewhere around the world. Interactive online meetings, an online message board and 24/7 chat room are also available to support anyone with Internet access.

SMART Recovery is an abstinence-based approach. It is open to individuals who are abstaining, and to those who are considering but have not yet committed to abstinence. SMART’s 4-Point Program encompasses the following areas:

  1. Building and Maintaining Motivation
  2. Coping with Urges
  3. Managing Thoughts, Feelings and Behaviors
  4. Living a Balanced Life

The SMART approach offers skills training for emotional and behavioral self-management. Using a variety of cognitive tools and a motivational interviewing style of interaction, SMART Recovery:

  • Teaches self-empowerment and self-reliance
  • Provides meetings that are educational, supportive, and include open discussions
  • Teaches techniques for self-directed change
  • Evolves as scientific knowledge of addiction recovery evolves
  • Supports the scientifically informed use of psychological treatment and legally prescribed psychiatric and addiction medication

In SMART Recovery’s self-empowering approach, participants are encouraged to take responsibility for their choices as they work on their individual recovery paths.


SMART Recovery meetings are structured to allow participation by all in attendance. Meetings start with the facilitator checking in with each participant after which an agenda is set based upon participant input. Open discussion follows and cross-talk is encouraged. All meeting facilitators and online volunteers complete a 30-hour training course in SMART Recovery tools and meeting practices.


SMART Recovery is recognized as a resource for addiction recovery by numerous organizations including the National Institute on Drug Abuse (NIDA), US Department of Health and Human Services, American Society of Addiction Medicine (ASAM), American Academy of Family Physicians, and the National Association of Drug Court Professionals (NADCP).

For more information about how to participate in face-to-face or online meetings, or to learn how to start a SMART Recovery meeting in your area, visit

1. National Center on Addiction and Substance Abuse at Columbia University, CASA Columbia 2012 Report on Addiction Treatment.

2. A Message of Tolerance and Celebration: The Portrayal of Multiple Pathways of Recovery in the

Writings of Alcoholics Anonymous Co- Founder Bill Wilson; William White, M.A. and Ernest Kurtz, Ph.D.

Roxanne Allen has been a volunteer for SMART Recovery since 2009. She is a co-developer of the SMART program for Family & Friends and currently serves on the Board of Directors.

Tuesday, September 9, 2014

FASD Awareness Day 2014: September 9

During September, events across the nation share the message of Recovery Month, that prevention works, treatment is effective, and people can and do recover.  Along with the 25th anniversary of SAMSHA’s National Recovery Month, 2014 also marks the 15th Annual observance of FASD Awareness Day, sponsored by SAMHSA’s FASD Center for Excellence. (

As Frances M.Harding, Director of SAMHSA’s Center for Substance Abuse Prevention writes on the SAMHSA Blog, “When a pregnant woman drinks alcohol, so does her baby.” Yet the risks of maternal drinking during pregnancy and the link to Fetal Alcohol Syndrome Disorder  (FASD) have come to our attention fairly recently.  As Dr. Kenneth Warren, deputy director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) notes in this month’s ATTC Meet the Researcher Profile,

“At the time I entered the FASD field (mid-to-late 1970s), there lacked general acceptance by the medical community, scientific community, and the public, that alcohol posed risks for the unborn fetus.”

Current research is uncovering more and more evidence of the long-term consequences of prenatal exposure to alcohol. One recent study examines the link between FASD and childhood obesity. You can read a research brief of the full article “Prenatal alcohol exposure is associated with later excess weight/obesity during adolescence,” an Addiction Science Made Easy article for September 2014.

Research is also showing that children diagnosed with FASD are at greater risk for developing an alcohol or other substance use disorder later in life—and the problems with behavior and learning that often accompany FASD require modified treatment approaches.

The Centers for Disease Control and Prevention estimates that as many as 40,000 babies are born each year with FASD. To find out more about this preventable disorder, join the free webinars that the FASD Center for Excellence is presenting today, September 9:

Awareness of Fetal Alcohol Spectrum Disorders: Making the Connections!
1:00-2:00pm EDT 
Learn about the connections and progress of collaborative efforts from various perspectives of FASD.

Addressing Fetal Alcohol Spectrum Disorders
Treatment Improvement Protocol (TIP) 58
3:00-4:00pm EDT
Learn more about SAMHSA's new landmark publication Addressing Fetal Alcohol Spectrum Disorders, #58 in the Treatment Improvement Protocol (TIP) series, the first TIP in the series to directly address the topic of FASD.

To register for either or both webinars, go to: FASD Awareness Day 2014 Events

The webinars will be recorded, and the PowerPoints, transcript, and recording will be posted on the FASD Center for Excellence website (

Thursday, September 4, 2014

Earth Day, Google Doodles, and the Recovery Movement

Kimberly Johnson, MSEd, MBA
NIATx Deputy Director
Co-Director, ATTC Network Coordinating Office

Earth Day image
At first, it seemed like a radical idea, with Rachel Carson and scientists talking about how industrialization was destroying our environment, but on the first Earth Day on April 22, 1970, 20 million Americans took part in rallies across the nation to demonstrate for clean air and water. A wave of legislation after the event created United States Environmental Protection Agency and led to the passage of the Clean Air, Clean Water, and Endangered Species Acts.

Earth Day raised consciousness and created fertile ground for research on ways to protect the environment. As a result, many environmental issues have improved in the U.S.: we have cleaner air and water, and thanks to recycling, we send much less garbage to landfills. Anyone that can remember the 1970’s knows that there has been a tremendous improvement in the environment here in the U.S. Earth Day is a now an international event that’s noted on calendars and even has its own Google doodle.

What if we could make the substance use disorders as rare as dumping chemical waste into the water? What if we applauded addiction recovery as widely as the return of an endangered species?
This month marks SAMHSA’s 25th National Recovery Month, with the theme “Join the Voices for Recovery: Speak Up, Reach Out.” Events and activities across the country are encouraging people in recovery to “go public” about how they live recovered lives. One event that you won’t want to miss is SAMHSA’s live, interactive webcast at 12 noon CST on September 15, Recovery and Health: Echoing through the Community. SAMHSA is encouraging organizations to take action and set up “Echo Events”— community organized meetings held in tandem with the webcast. Find out how you can host your own Echo Event.

National experts on the SAMHSA webcast include recovery movement leader William White, who has also contributed the feature article “Tribute to the Recovery Movement” to the September ATTC Messenger. And our Third Thursday iTraining (September 18, 2pm EST) this month features speakers from Young People in Recovery.

You'll also want to mark your calendars for Wednesday, September 17, 2-4pm EST, when  the Office of National Drug Control Policy (ONDCP) is hosting Recovery at the White House. You're invited to host a viewing party of the event, which will be broadcast live on This event will feature tweets with questions for panelists in recovery on stage. To find out more, contact Nataki MacMurray at

All of these activities underscore the message delivered in SAMHSA's Recovery Month Kick-off webcast on September 4. Combating the public health crisis of addiction requires a coordinated effort among addiction treatment providers, government officials, law enforcement, researchers, schools, churches, community groups, families…anyone and everyone affected by addiction.

I used to want a ribbon or a wristband for the Recovery Movement. Now I’m thinking Google Doodle. Why? Who cares? Because a symbol of recognition that reaches beyond those of us working in the field or in recovery ourselves is an important marker. If we are ever going to clean up our environment and make addiction rare and recovery lauded, we need to build the movement, gain the attention of the general public, all of whom are affected by substance abuse in some way, and make every month Recovery Month.

Kimberly Johnson, NIATx Deputy Director and ATTC Network Coordinating Office Co-Director, served for seven years as the director of the Office of Substance Abuse in Maine. She has also served as an executive director for a treatment agency, managed intervention and prevention programs, and has worked as a child and family therapist. She joined NIATx in 2007 to lead the ACTION Campaign, a national initiative to increase access to and retention in treatment. She is currently involved in projects with the ATTC Network and NIATx that focus on increasing implementation of evidence-based practices, testing mobile health applications, and developing distance-learning programs for behavioral health. 

Tuesday, August 12, 2014

What we can learn from the McRib and wind power

Dave Gustafson, PhD
Director, Center for Health Enhancement Systems Studies and NIATx
University of Wisconsin-Madison

I find it difficult to clearly explain why it is so important to go outside the field for ideas on how to improve and how to get those ideas. So I am going to try again. One of these days I will get it right.

A lot of people are becoming pretty good at understanding the needs of their customers. The walk-throughs are being used pretty extensively as well as nominal group and focus group meetings. It is exciting to see that happening. And of course it is natural to say: "Well, now that we understand the problem, let's solve it.” I love rapid-cycle improvement!

But there is a risk that we will jump to an obvious solution. The obvious solutions are very likely to have been tried in SUD before. And they may have worked, or they may have worked a little, or worked a lot for a while and then stopped working. So it probably does not hurt to take a one-hour detour to cast a wider net for solutions. Where do we find those solutions? From concepts and problem-solving efforts of people who are tackling a similar problem but in a different industry.

Suppose we were trying to find a way to get people to keep coming back for treatment. What other industries worry about getting people to come back on a regular basis? Lets think out of the box for a second. Well, there is television. They try to get us to come back to their shows. And there are fast food restaurants. Of course there are many others. But let's go with those two for a minute.

We have found the industries. Now we need to find the best of the best in those industries. In many cases they will be obvious. In fast foods, it is probably McDonalds. They must invest enormous amounts of effort in getting people to return. How do they do it? One of us knew the head of marketing for McDonalds, but you could just as easily Google. For instance, I Googled "How does McDonalds get people to return?" I found millions of responses because many people have studied McDonalds. One thing that comes up over and over again in the few summaries I read was that they segment their customers and find out what those people respond to. Then they target those things people respond to.

The first article pointed out the McRib. Its nutrition is terrible and a lot of people hate it. But a big segment (typically young guys) of McDonalds customers really like it. So what? Well, McDonalds thinks about what would bring those people back. They hit TV programs with a young guy who is going on his honeymoon and he gets a text from a friend saying McRibs are back. For a few seconds he debates whether he wants to go on his honeymoon with this wife watching, perplexed.

What can that story tell us about how to keep our patients coming back? McDonalds would say that one size does not fit all. In our field some may respond to threats, others to reminders, others rewards, etc. But rarely do the same things work for everyone. What if we began to create a database of what our customers respond to? Try some things, see what happens, and then put those results into the database, so we know what to try (or not try) to get each person back.

A similar approach could be taken by a behavioral health organization as it finds its place in the implementation of the Accountable Care Act; specifically attracting new third-party payers. What industries have a similar challenge? Maybe windmill manufacturers? They have always produced energy (initially for grinding grain).  Now they are moving aggressively into clean power. Who are the best of the best and how do they make that move? A quick Google Scholar search turned up several articles including one that followed adoption of wind power in Europe. 

They discussed three strategies that were important to its success:  

1) stimulating technological progress; 
2) minimizing administration and transaction costs of adoption, and 
3) gaining public acceptance for wind energy. 

The question is, how can we learn from that?  One might be to really make adoption very easy and inexpensive; to engage in a marketing effort to help the public get excited about the idea and have technological support systems, and maybe to help adopters track the benefits (and costs) of their decision in real time.

How long would it take you to: 1) Identify other industries that deal with a problem similar to ours? 2) Identify one of the best organizations at solving that problem in that industry? 3) Ask Google Scholar to identify what makes McDonalds (or whatever) so good? 4) Read at least the abstract of a couple of articles? 5) Ask, “What is it that they do that could be helpful for us?”

I would say one hour, two at most. I think it’s worth it.

An earlier version of this blog post originally appeared on the NIATx website in November 2011.

Monday, August 4, 2014

Connect, learn, and implement with the new Network of Practice

Kim Johnson

NIATx Deputy Director
ATTC Co-Director (WI)

Have you ever been frustrated by the whole evidence-based practice (EBP) thing? First, are EBPs really worth it? Does the difference for the clients make EBPs a worthwhile investment? And then, which ones do we use? Because really, it will probably take more than one anyway, right? So then the question becomes which combination of EBPs work together best for our particular clients. And if you’re the supervisor and you talk to the clinicians in your practice, they all say, “I’m already doing that,” and they’re insulted if you suggest that they aren’t, as they should be—because they are probably doing it as well as they can, given the resources they have. 

It can get to be overwhelming.
But many states have started to require contracted treatment organizations to demonstrate that they have implemented evidence-based practices, and other funders are now requiring improved treatment outcomes. 

Implementing evidence-based practices is probably in your future, even if it hasn’t been in your past.
Back in 2011, NIATx and the ATTC held a series of focus groups around the country to ask providers, CEOs, clinical supervisors, and direct service staff about the barriers they face in implementing EBPs. We asked what would help overcome those barriers. Then we looked at the implementation science literature (yes, there is an implementation science) and we developed a web tool called The Network of Practice:
What we heard the most in our focus groups with treatment providers was that they wished they had someone to talk to—someone who knew about a specific EBP and how to implement it. The Network of Practice is home to a new electronic community that will connect you to your peers and the researchers that develop EBPs. You can use these forums to ask questions, get and give advice, and just talk with each other about how to improve your treatment outcomes.
Over the past month, we had a group of users test the Network of Practice materials and start the conversation. We hope you will join in and share your wisdom and experience, as well as your hopes and frustrations. 

In return, we promise to find the answers to your questions, welcome your ideas and suggestions, and keep the pages fresh with the latest information about EBPs. 
The Network of Practice features other tools we developed to address issues people raised in the focus groups.
The cost benefit survey can help you figure out if the benefits of EPB for the clients outweigh the costs to your agency. You can use another tool, the readiness for implementation scale (RIS), to identify your organization’s strengths and weaknesses in terms of implementing a new EBP. 

We also linked to other web tools and resources such as SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP) and NIATx and ATTC materials. And we organized all the tools and info in a step-wise process that will guide you from your initial thinking about a particular EBP through the process of testing and adopting it throughout your organization.
Post a comment or question three times during the month of September, and you’ll be entered in a drawing to win one of 3 Kindle Paperwhites. Visit the site today, and let us know what you think!

Kimberly Johnson, NIATx Deputy Director and ATTC Network Coordinating Office Co-Director, served for seven years as the director of the Office of Substance Abuse in Maine. She has also served as an executive director for a treatment agency, managed intervention and prevention programs, and has worked as a child and family therapist. She joined NIATx in 2007 to lead the ACTION Campaign, a national initiative to increase access to and retention in treatment. She is currently involved in projects with the ATTC Network and NIATx that focus on increasing implementation of evidence-based practices, testing mobile health applications, and developing distance-learning programs for behavioral health. 

Monday, July 28, 2014

Change is easy...

Director of Research
Center for Health Enhancement Systems Studies/NIATx 
University of Wisconsin-Madison

But staying changed can be a challenge.   

Maybe you’ve seen it happen in your own organization: an improvement project has an initial success…then fades into improvement project oblivion a few months later.

Just as losing weight doesn't mean that it will stay lost, implementing an organizational change doesn’t guarantee that it will be sustained. Studies indicate that only 40 to 70% of changes are sustained[i].A change not sustained is a direct waste of invested resources, creates costs associated with missed opportunities, and affects your organization’s ability to implement change in the future.

Despite these challenges, we are learning more about what makes change “stick,” or the attributes that influence sustainability of organizational change. But before I tell you about these attributes, I want to clarify two important related concepts: maintenance of change and organizational capacity to maintain the benefits of a change.  How do they differ? 

I like to define maintenance of change as “the extent an evidence-based intervention can deliver its intended benefits over an extended period of time.[ii]” 

Take a look at weight loss. For a dieter, maintenance of change might be the ability of reduced calories and increased activity to deliver the intended benefit (a healthy weight) over time. For an organizational improvement project to reduce appointment no-shows, maintenance of change might be the extent to which using reminder phone calls reduces no-shows, once that practice is adopted as standard procedure.  

Organizational capacity to maintain the benefits of change refers to the existence of structures and processes that allow a program to leverage resources to effectively implement and maintain evidence-based policies and activities.[iii]” In other words, how does the organization’s environment support sustaining the improvements made?  Creating a culture of change can make all the difference in sustaining a new business process or an evidence-based practice.

Long-term success

What I do know is that the longer your organization maintains the benefits of a change, the more likely those benefits to become the “new normal.”   

 Let’s say you make changes to reduce waiting time for first appointments from 28 to 7 days. After testing a few promising practices such as reminder phone calls, double booking appointments, and offering same-day service, you successfully reducing waiting time to 7 days.  Even better, you maintain that improvement over a 12-month period! Admissions are up, and more clients are continuing in treatment. The increase in billable hours has boosted revenue, and your board of directors is pleased. The expected appointment wait time of 7 days is now the new normal for your organization, and you would measure any efforts to improve wait time further against this internal benchmark.

A sustainability focus
Two aspects of sustainability do not get enough attention in quality improvement projects: lack of focus on sustainability early in the implementation process and sustainability planning.  Think of yo-yo dieting: a person might achieve a dramatic weight loss by severe restricting calories and increasing activity. But can both changes be maintained over time? Does the dieter have a plan already in place for counting calories and staying active once the weight loss goal is achieved?

Organizations need to go into implementation believing that the change will be successful and should be sustained. The ideal time to start thinking about sustainability will vary, but once the change has been implemented and appears to be successful, it’s time for an organization to assess its capacity to sustain the change. Now’s the time to identify internal barriers to sustainability. I know about two tools to help assess your organizations’ sustainability capacity: (1) the British National Health Service Sustainability Index and (2) the Program Sustainability Assessment Tool. Regardless of the tool used, recruit four to eight staff persons in your organization to complete the tool to ensure that multiple opinions are considered when assessing sustainability capacity.

A sustainability plan
Use the results from the assessment to focus on sustainability planning. A sustainability plan identifies specific actions that an organization might take to support sustainability.

In my opinion, a sustainability plan should be simple and concise. It should formalize the infrastructure and identify the resources to support sustainability. For example, the plan should identify a sustain leader and the process that will be used to regularly monitor the impact of the change over time. The sustain plan can been seen as your “relapse prevention plan” should the change begin to fail. Similar to when a fire alarm is pulled and you need to evacuate the building, the sustain plan should identify the red flags or triggers that will stimulate action.

Let’s go back to the example of the organization that reduced waiting appointment wait time to 7 days. Your organization decided that the red flag would be appointment wait time creeping up to 10 days for two consecutive weeks. Your sustain plan should clearly define immediate steps to take when that happens. These steps could include reconvening the change team in 48 hours to study the problem, identifying the source of the increase in appointment wait time, and then taking correctable actions.

These are some of my thoughts related to sustainability. Now it would be great to hear from you. Do you have a success story to share related to sustainability? What attributes influenced your organizational capacity to sustain change? How long have you been able to maintain the benefits from an implemented change? Are some changes easier to maintain than others? If so, what types of changes? Let’s start a dialogue so everyone benefits from our collective knowledge.

Dr. Jay Ford’s current research applies health systems engineering principals and techniques to improve health care delivery systems within behavioral health. Current projects involve community-based treatment providers, states, and the Veterans Administration. He serves as a coach for projects such as the Wisconsin Mental Health Learning Collaborative and BHBusiness. Previously, Dr. Ford led the research and data analysis for NIATx 200 and STAR-SI projects that focused on spreading and sustaining organizational change in addiction treatment organizations and systems. He was also a member of the team that developed and tested the NIATx model in the Robert Wood Johnson Foundation-funded and CSAT-funded Paths to Recovery and STAR projects

[i] Scheirer, M. A. and J. W. Dearing. 2011. “An agenda for research on the sustainability of public health programs.” American Journal of Public Health 101(11): 2059-67
[ii] Chambers DA, Glasgow RE Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013 Oct 2; 8:117
[iii] Schell S, Luke D, Schooley M, Elliott M, Herbers S, Mueller N, et al. Public health program capacity for sustainability: A new framework. Implement Sci., 2013 Feb 1; 8:15.

Friday, July 18, 2014

Twitter, baseball, and evidence-based practices

Maureen Fitzgerald
Communications Coordinator, ATTC Network Coordinating Office
Senior Editor, NIATx

Last month I attended a great workshop on science writing and communication skills for the 21st century. One of the featured speakers was Lee Aase, director of the Center for Social Media at Mayo Clinic. His workshop, “You Are Now the Media. Really” was about how social media is revolutionizing health care.

Aase got the Mayo Clinic started with social media, launching podcasts in 2005, Facebook in 2007, and Twitter in 2008. A TwitterChat about wrist surgery that Mayo Clinic hosted with USA Today (featuring the wrist recovery of Philadelphia Phillies outfielder Jason Werth) encouraged other people with similar wrist injuries to inquire about the surgery. Dr. Richard Berger, who pioneered this surgery (called the UT split), later wrote to Aase that several doctors had trained with him to learn the procedure because of the TwitterChat

Berger said, “Social media has driven this into practice in less than 2 years, when it takes 17 years on average!”

Could social media have the same effect on the spread of evidence-based practices in behavioral health?

Mayo Clinic also has a YouTube channel and several blogs. One of its most successful videos (with millions of views) was of an older couple playing the piano. You can watch the video and read the story of these “Octogenarian Idols” here.

Social media has been so successful that today Mayo Clinic has an entire department dedicated to it, the Social Media Health Network.

Aase says that before social media, the most effective communication channel for the Mayo Clinic was not paid advertising or TV spots, but word of mouth—patients referring one other to the clinic’s doctors.

Social media are the word-of-mouth of the 21st century.

In the 21st century environment of health care reform, behavioral health care organizations have to market their services and compete with one another. Social media, in all its forms—Facebook, LinkedIn, Twitter, YouTube, and blogging, to name just a few—have become essential and affordable marketing tools.

Has your organization made the leap?

If you’re looking for ideas and inspiration, check out the four-part social media webinar series Marketing with Social Media on the NIATx website. The first is a presentation by Lee Aase similar to the one I attended.

Aase also offers some fun and informative resources on his  Social Media University, Global (SMUG) website. For example, Twitter101: Intro to Twitter is just under three minutes and gives a great overview. You’ll be happily tweeting away before you know it.  

Oh, and by the way, be sure to "follow" us on Twitter:

and "like" us on Facebook: 

…and we’ll be sure to follow you and like you back!