Using Text Messages to Improve Substance Use Disorders Treatment Outcomes

Nancy Roget, MS, MFT, LADC
Co-Director, Mountain Plains ATTC

Annually, the Substance Abuse Mental Health Services Administration (SAMHSA) conducts a survey called the National Survey on Drug Use and Health (NSDUH). This survey interviews almost 68,000 individuals across the nation regarding their use of alcohol, prescribed medications, and illicit drugs. In 2019, the NSDUH survey found that almost 20 million individuals over the age of 18 had a substance use disorder (SUD), with less than 10% of these 20 million receiving treatment services. To address this vast treatment gap between individuals who report having a SUD and those that enter treatment, both researchers and policy-makers advocated for strategies that increase access to treatment services, promote low-cost resources, and offer engagement activities. An innovative response suggests that behavioral health technologies may offer one solution.

According to Ashford and colleagues (2018), in the last decade the use of technology by
SUD treatment and recovery support providers has helped increase the reach of their services, lower the threshold for patient engagement (e.g., made it easier for patients to enter treatment or recovery support services) and offer services that serve as an adjunct or complement to treatment and recovery services (p.19). At the same time, the use of technology (e.g., mobile phone, smart phone, tablet, computer, and internet) has increased in the general public. Recent data from Pew (2019) found that 81% of adults owned a smartphone, which was up 4% from 2018, and 73% had high speed internet at home. Smartphone use has increased among SUD treatment populations as well, with smartphone ownership ranging from 57% to 80% (Ashford et al., 2018; Dahne & Lejuez, 2015; Milward et al., 2015; Winstanley et al., 2018). These reported smartphone ownership rates for individuals involved with SUD treatment services have increased dramatically from an initial study done in 2013. Mobile phone ownership for this population increased substantially as well, ranging between 83% and 95%. Access to the internet is still low for the SUD treatment population but most individuals reported accessing internet services through their phones rather than home broadband. The bottom line as highlighted in the above-mentioned studies is that most patients have access to a mobile phone that can be used to receive or send text messages and/or to access the internet. Finally, a recent study (Ashford et al., 2018) showed that individuals in SUD treatment expressed a strong interest in using digital resources to manage and monitor their recovery, which included their preference to use an app on their phone or receive text messages. 

In light of these recent findings on technology use and patient feasibility/interest data, the Mountain
Plains ATTC worked with Dr. Scott Walters, a noted professor, National Institute on Drug Abuse (NIDA) researcher, and psychologist to develop a series of products and training/technical assistance activities. These products and activities were created for treatment and recovery support providers on how to create and implement one-way short message service (SMS) text messaging. The goal of implementing this innovation was to increase patient/peer engagement aligning with services like groups/individual sessions. A text messaging curriculum was created by Dr. Walters and piloted by the Mountain Plains ATTC in a two-part webinar series in Spring 2019, after which revisions were made to the manual and webinars, and a text messaging poster created that reminds providers and peers about texting language and tips. In August 2019, the webinar series was facilitated again, recorded, and posted in the products section on the Mountain Plains ATTC website along with the poster and manual. In November 2019, a small four-week intensive technical assistance (ITA) pilot was implemented with six SUD treatment providers located in Region 8 to assist with the implementation of text messaging within one of their treatment/recovery support components. Currently, these six providers are participating in the last part of the ITA project that includes individualized consultation sessions with Dr. Walters to assist with implementation issues. Results from this ITA project will be posted under a ‘lessons learned’ document. Initial feedback from participants reflects the principles of technology transfer that the innovation was easy to use, met a need at the agency, and enhanced their current service delivery. A recent Norwegian study by (Bjerke et al., 2009) on the use of text messaging found that patients felt a greater sense of connectedness to the providers through the use of text messaging. The Mountain Plains ATTC staff hopes the providers involved in this project receive similar patient feedback.

Ashford, D. R., Lynch, K., & Curtis, B. (2018). Technology and social media use among patients enrolled in outpatient addiction treatment programs: Cross-sectional survey study. Journal of Medical Internet Research, 20(3), e84.

Bergman, B. G., Greene, M. C., Hoeppner, B., & Kelly, J. (2018). Expanding the reach of alcohol and other drug services: Prevalence and correlates of US adult engagement with online technology to address substance problems. Addictive Behaviors, 87, 74–81.

Bjerke, T. & Kummervold, P., Christiansen, E. & Hjortdahl, P. (2009). “It made me feel connected”—An exploratory study on the use of mobile SMS in follow-up care for substance abusers. Journal of Addictions Nursing, 19, 195-200. 10.1080/10884600802504735.

Bliuc, A. M., Best, D., Iqbal, M., & Upton, K. (2017). Building addiction recovery capital through online participation in a recovery community. Social Science & Medicine, 193, 110–117.

Dahne, J. & Lejuez, C. (2015). Smartphone and mobile application utilization prior to and following treatment among individuals enrolled in residential substance use treatment. Journal of Substance Abuse Treatment, 58(Supplement C), 95–99.

Masson, C. L., Chen, I. Q., Levine, J. A., Shopshire, M. S., & Sorensen, J. L. (2018). Health-related internet use among opioid treatment patients. Addictive Behaviors Reports, 9, 100157. doi:10.1016/j.abrep.2018.100157

Milward, J., Day, E., Strang, J., & Lynskey, M. (2015). Mobile phone ownership, usage and readiness to use by patients in drug treatment. Drug and Alcohol Dependence, 146(Supplement C), 111–115.

Pew Research Center (2019). Mobile Technology and Home Broadband 2019. Accessed January 2020 from

Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from

Winstanley, E. L., Stroup-Menge, B., & Snyder, K. (2018). The promise of technology-based services for addiction treatment clients residing in nonurban areas. Journal of Studies on Alcohol and Drugs, 79(3), 503–504.

Changing Practice Through Collaboration, Art, and Science

Respectfully submitted by Holly R. Ireland, LCSW-C

The Central East ATTC serving Health and Human Reserves Region 3 has been managed by the Danya Institute for nearly 20 years. Danya’s tagline is “Changing Communities Through Changing Practice” and collaboration has always been a central core value to our work. Workforce development and capacity building changes in practice could not be successfully sustained without collaboration. The mutual exchange of perspectives, ideas, and investment leads to richer and more lasting changes for systems, organizations, professionals and most importantly the individuals and families receiving behavioral healthcare. From it emerges the necessary innovation to keep pace with rapidly evolving trends, leading to a responsive and adaptive system of care.

In recent years there has been an emerging "science of collaboration."[1] This involves intentional efforts to measure the process of learning what works and what doesn't, then use data-informed decision making to improve how leaders design, manage, and evaluate collaboration projects. The process helps to educate and train future leaders with the necessary organizational and managerial skills in collaboration. Literature about the science of collaboration emerged historically in the science sector but is increasingly found in the health and behavioral health sectors.

Given Danya’s core value and the SAMHSA imperative to accelerate the adoption of evidence-based practices in behavioral health through intensive technical assistance (TA) to organizations, localities, and systems; the Central East ATTC has implemented several intensive TA capacity building collaborative projects in organizations, municipalities, counties, and statewide and regional systems of care. Stakeholder collaborations involving three or more entities or organizations have been central to implement capacity building projects in the adoption of evidence-based practices in Motivational Interviewing (MI) and Screening, Brief Intervention, and Referral to Treatment (SBIRT).

In Year 1, the Mount Rogers Community Services Board (MRCS)[2] in Wytheville, VA, collaborated with the Central East ATTC to increase Motivational Interviewing (MI) capacity. MRCS offers “a wide array of community services for individuals with mental health, intellectual and developmental disabilities, and substance use disorders. All services include the use of person-centered planning and embrace concepts of self-determination, empowerment, and recovery as core principles in supporting individuals to achieve their highest possible level of participation in work, relationships, and all aspects of community life.”[3] Candace Coffin, Director of Specialty Services –
Administration/Training, was the champion and internal facilitator of this project. The Central East ATTC engaged Christine Higgins, MINT Trainer, subject matter expert and external facilitator, to plan and implement this project. As part of the planning process, 20 staff members, mostly clinical supervisors, were identified and engaged as key collaborators and future MI trainers.

In Year 2, the project was launched in November 2018 and concluded in September 2019. It began with an MRCS Senior Leadership dinner meeting, which provided an overview of the 6-9 month project; and included two (2) back-to-back, one-day MI Basic training events on November 1 and 2, training 72 staff members. Christine returned to Wytheville in December 2019 to provide MI intermediate training to 24 staff members and clinical supervision of MI training to 22 supervisors.

From December through March, there were several virtual TA sessions with Chrisitine and the 22 supervisors, both group and individually, that involved video recording, coding and feedback, as well as coaching in the supervision of MI. To enhance relationship building, engagement and collaboration for the in-person and virtual sessions between Christine and the trainees, Candace created name placards with photos.

In March 2019, Christine provided MI Advanced to 14 of the supervisors, and 20 of them participated in an MI Training of Trainers in April 2019.

From April through September 2019, Christine provided an additional 20 hours of virtual TA to support the training plan development and implementation, as well as additional coaching in clinical supervision.

The MRCS MI Spirit Committee was formed to ensure full integration of MI in the onboarding of new staff, training of the existing 700+ staff members, and maintenance of a robust commitment to the spirit of MI throughout the work of the organization.

“We are so deeply grateful to the [Central East ATTC] for all the training – well worth it. Our trainers are ready and Christine has been a huge support.” - Candace Coffin.

MRCS continues to contract with Christine Higgins directly for the development of 15 minute video to show at new employee orientations to introduce Motivational Interviewing. They also have a monthly training calendar for two-day MI training sessions from March through December 2020. The MI Spirit is strong at MRCS and the change in practice will endure.




NIATx Tools: What I Learned From My First Walk-through Exercise

Julia Parnell Alexander, Ph.D.
Co-Director, Great Lakes PTTC
State Project Manager, Indiana, for the Great Lakes ATTC, MHTTC, and PTTC

My first NIATx walk-through exercise happened when I was a staff member at a recovery community organization (RCO) in Minnesota. Through this experience, I quickly learned the difference between theory and practice.

I thought I knew our organization well, quite well. A core principle of an RCO is that it is welcoming and serves everyone in the community. We had worked hard to make our space welcoming, and we had organized many events and gatherings over the years that drew large crowds that filled the space with joy and laughter. My confidence in our space, our work, and our welcoming nature was so strong that I thought the walk-through experience would confirm my views. Our welcoming environment, I thought, was solid, with little or no room for improvement.

Cut to the actual walk-through. I did everything I could to leave my routine behind. What would fresh eyes tell me? How could I start from scratch?

I entered our address into Google Maps. I had never Googled the address before because I usually drove to work—because I knew right where to go, right? Google produced two locations. Which one was correct? The address information was confusing, so I decided to call the office to find out what to do. With help from the staff person on the phone, I chose the correct option and made a note to self to get this corrected with Google Maps.

I pulled into the parking lot and was happy to see ample parking. And then it hit me: I’d heard people say that the RCO entrance door was not clearly marked, but it finally resonated for me when I was trying to decide where to park. There were three entrance doors, and I wasn’t sure which one to use. Plus, there was no signage indicating where to go and nothing to differentiate the RCO from the church that hosts the RCO. Was I in the right place?

I first chose the front door, figuring it would lead me to someone who would direct me where I needed to go. This door was locked. Pulling on a locked door felt like rejection. I bypassed the middle door—it looked like something only a staff member would use. Next, I went to a set of double glass doors at the opposite end that looked more inviting and “official.” Nope, these doors were locked as well. Rejected again. I doubled back to that middle door, and it was open. Success! But that feeling was fleeting as I walked into a grand and empty open space. It was bright and spacious, but it was empty. I still didn’t know where to go. Walking toward the sound of lively chatter, I found friendly people who greeted me with a jovial and authentic welcome—finally! It had just taken a lot of work to get there. And it turns out that people don’t really like to provide a critique of their experience when it’s uncomfortable. And we certainly never heard from people we never met because they simply gave up trying to get to us.

My experience was just one type of a walk-through, but it gave insight into a core element of what we were assessing as an RCO. My walk-through led to a few changes: we added signage outside the best entrance to use, and we posted volunteers in an office inside near the entrance so they could immediately welcome visitors. These changes helped make our space much closer to the welcoming nature I had initially thought we had.

If you do your best to do your walk-through with fresh eyes, taking nothing for granted. You’ll be surprised by how much you learn, and you’ll have ample data to use in your change project. It’s key that you conduct the walk-through with an open mind and an eye towards improvement without assigning blame as you go. A walk-through exercise isn’t about monitoring staff or about improving performance—it’s about improving a process.

Visit the newly updated NIATx website to learn more about the walk-through process. You’ll find complete instructions and forms under the “Tools” tab.

We’d love to hear insights from your walk-through experiences. What did you learn? What changes did you make or change projects did you do as a result of your walk-through? Share your experience in the comments section below.

About our guest blogger
Julia Parnell Alexander, Ph.D., is a woman in long-term recovery. Before her work with the Great Lakes ATTC, MHTTC, and PTTC, she was a founding staff member of and then served as Executive Director of Operations for Minnesota Recovery Connection, Minnesota’s first and longest-running Recovery Community Organization.

Tech Transfer in Action Blog Series: Infusing Evidence-Based Substance Use Disorder Treatment and Recovery Information into Existing U.S. College and University Curricula

Beth Rutkowski, MPH
Co-Director, Pacific Southwest Addiction Technology Transfer Center, HHS Region 9

Developing a competent, highly skilled multidisciplinary workforce to provide effective treatment and recovery services to individuals living with a substance use disorder is a cornerstone of the training and technical assistance occurring throughout the SAMHSA-funded Addiction Technology Transfer Center Network. To be most effective, workforce development should begin at the pre-service education level, so that as new professionals graduate and enter into the field, they have the advantage of being equipped with the most up-to-date, science-based clinical tools.

For this reason, a key element of the Pacific Southwest ATTC’s five-year work plan is the development and distribution of a series of Curriculum Infusion Packages (CIPs) on a variety of targeted topics. The first, a 5-part CIP on Opioid Use Disorders (OUD), was developed and released in late summer/early fall 2019. The main developers were Beth Rutkowski, MPH, and Nancy Roget, MS, with additional guidance and editing support provided by Terra Hamblin and Drs. Thomas E. Freese, Michael Shafer, and Joyce Hartje.

The OUD CIP was developed for college and university faculty to infuse brief, science-based OUD-specific content into existing substance use disorder-related course syllabi (e.g., foundations of addiction, screening and assessment, general health-related classes, etc.). Instructors can select the specific content to infuse throughout the duration of the course, depending on specific needs of the learners. Each slide contains notes for the instructor to provide guidance, as necessary. References are included in each slide and handouts when possible.

Part 1 of the OUD CIP provides an overview of addiction as a brain disease, a description of opioids and how they work in the brain and body, the acute and chronic effects of opioid use, the epidemiology of the opioid epidemic, and resources for continued learning. Part 2 discusses the importance of integrated, holistic care for people with OUDs, tools to address the opioid epidemic, the difference between an opioid agonist and antagonist, a review of FDA-approved medications for OUD, and resources for continued learning. Part 3 reviews opioid overdose and prevention strategies. Part 4 provides discusses of the importance of using language that helps decrease stigma associated with SUDs. Lastly, Part 5 provides an overview of recovery supports and treatment recommendations for people with opioid use disorders.

The slide decks are designed to be used by academic faculty in behavioral health programs, trainers, behavioral health providers, and state/county agency staff members for a variety of audiences. Educators are free to use these slides and the pictures, but are asked to provide credit to the Pacific Southwest ATTC when using them by keeping the logo on each slide and referencing the Pacific Southwest ATTC at the beginning of their presentation(s).

For the Opioid CIP, the Pacific Southwest ATTC developed a two-part marketing and dissemination strategy. Wave 1 distribution occurred in August 2019 and targeted more than 160 colleges and universities across HHS Region 9 with a nursing, social work, psychology, and/or SUD counseling program or school. Wave 2 distribution occurred in September 2019 and targeted an additional 90 Region 9-based colleges and universities with a medical, criminal justice, community health service, and/or public health program or school. In addition, leadership in all of the community colleges across the six U.S.-affiliated Pacific Jurisdictions received a link to the electronic copy of the CIP. In a two-month time period from October 1-November 30, 2019, the OUD CIP was viewed and downloaded more than 540 times. Subsequent CIPs will be distributed in a single wave, and the PSATTC evaluation team will follow-up with educators approximately one month following receipt of the new CIP to assess the usefulness of and satisfaction with the information featured in the packages.

Future CIPs released in Years 03-05 of the funding cycle will focus on a variety of topics, including:
  • Compassion Fatigue
  • Stimulant Use Disorders – Methamphetamine and Cocaine
  • Alcohol Use Disorders
  • Chronic Pain Management
  • Smoking Cessation Strategies

To view and download the OUD CIP, please visit: Additional information is available at or by emailing Beth at

Hepatitis C Prescriber Toolkit

Laura W. Cheever, MD, ScM
Associate Administrator for HRSA HIV/AIDS Bureau

Although advances in HIV care and treatment result in longer life expectancy for people with HIV, those who are coinfected with HIV and hepatitis C have a high risk of liver-related illness and death. Viral hepatitis progresses faster and causes more liver-related health problems among people with HIV than among those who do not have HIV. Approximately 25% of people with HIV are coinfected with hepatitis C.

Providers are key partners in national efforts to reduce and, ultimately, eliminate hepatitis C virus (HCV) coinfection among people with HIV. To support providers in diverse settings to effectively engage and remain up to date on state-specific prescribing requirements, the Health Resources and Services Administration’s HIV/AIDS Bureau released the Hepatitis C Prescriber Toolkit on TargetHIV.

The interactive Hepatitis C Prescriber allows providers to select their state and learn about health coverage requirements that may impact the prescription of hepatitis c treatment. The toolkit also includes additional resources such as links to the Ryan White HIV/AIDS Program (RWHAP) Part F AIDS Education and Training Center (AETC) Program’s HIV/HCV Coinfection Curriculum.

Each state-specific page provides a link to the regional AETC partner for training opportunities and additional coinfection resources. , It provides information on Medicare, the state’s Medicaid contact, the state’s AIDS Drug Assistance Program (ADAP) contact with applicable prior authorization form. Providers can also access a list of patient assistance programs if their patient is not eligible for private insurance or ADAP coverage. 

Through the efforts of the RWHAP AETCs, a number of resources have been developed to support RWHAP recipients and providers to encourage increasing hepatitis C screening and treatment to help improve the health outcomes of people with HIV. The Hepatitis C Prescriber Toolkit is one more resource for providers to have at their disposal.

Visit the toolkit today! 

Supporting the “MI Spirit” Through an Intensive TA Process: Clinical Supervisory Staff Improve Their Communication Skills For Use with Clients and Each Other

Laura Cooley
Northwest ATTC Technology Transfer Specialist

How would you rate your skill level in motivational interviewing (MI)?
On the first day of a two-day MI workshop, 35 behavior analysts were asked this question about their perceived skill and confidence level in using MI. The behavior analysts, all of whom work as clinical supervisors at a Washington-based organization, proceeded to line themselves up in the training room according to self-ratings on a 0-10 scale (from ”not at all ready” to ”extremely ready”). One small group thought they had a very low level of ability in this area, two placed themselves in the intermediate to high range, and the rest ranked themselves somewhere in the middle.

The workshop was the start to an intensive technical assistance (TA) process led by the Northwest ATTC in partnership with Connections Behavior Planning and Intervention, LLC. The results of this TA process, which relied on use of an adapted EPIS (Explore-Prepare-Implement-Sustain) model, proved to be impressive:

By the end of the intensive TA process in MI, 96% of survey respondents reported intermediate or better confidence that they would be able to maintain use of the techniques they had learned after more than half a year of sustained technical support.

Today, an internal implementation team at the organization is busy putting the “MI spirit” into action by using their MI skills with clients, on-boarding new staff, or coaching their colleagues.

Getting the “buy-in” to take on this intensive TA was the easy part; Connections’ senior leadership team, James Kidwell and Paul Mullan, recognized MI’s value and wanted to improve staff satisfaction. They saw MI as a core skill that could “…both improve their staff-client interactions and be helpful in improving staff interactions with other staff,” said Mullan.

Dusty Dixon, director of continuing education, added, “From the start, we were committed to doing this because we recognized that ongoing practice and feedback are in line with our understanding of best practices.”

A real strength of this project has been the plan for sustained support from a highly skilled MI trainer, Dr. Ann Marie Roepke, who supported Connections on two levels:

  1. Virtual sessions focused on specific MI skill development and practice, and
  2. Creation of an internal implementation team to lead and sustain the improved MI capacity.
Commitment of senior leadership has been crucial. Senior leadership actively took part in the TA process and further demonstrated their buy-in by freeing up staff time. They committed the organization to the effort over the long haul and dedicated time normally allocated for administrative duties to further MI coaching.

IMPLEMENT The 5 main phases of this TA process consisted of:
  1. A two-day, in-person training on motivational interviewing;
  2. A series of videoconference calls over a 7-month period focused on further MI skill development and practice;
  3. Targeted observation of staff who volunteered to be observed as they practiced their MI skills, and some observation of senior management communication styles;
  4. TA coaching and support to an internal sustainability implementation committee; and
  5. Creation of a set of recommendations for sustaining MI skills at the organization.

Flexibility was intentionally built into the intensive TA process to ensure staff would have ample opportunity to practice their skills. They also received personalized, expert feedback from Dr. Roepke.

Coaching was offered through targeted observation of staff who volunteered to demonstrate their skills and discuss strengths and areas for further development. For the implementation team, this ongoing support proved to be “immensely beneficial,” according to Dixon.

Using videoconferencing helped meet the needs of the organization’s co-located staff. Sustained coaching of MI skills over several months led to implementation team members learning the basics of how to code MI skills. They can now coach new employees through on-boarding and model MI skills for others.

Keeping development and refinement of MI skills in-house is an organizational priority. As part of the sustainability plan moving forward, Connections staff have been revising some of their policies and procedures. These have “…shifted to align better with the ‘MI Spirit,’” says Dixon, who has been an in-house champion and key to facilitating the entire process. Another key in-house champion, David Cole, who directs their training programs, worked with the implementation team to promote MI’s use organizationally. MI is now being used to refine the training and coaching offered during the onboarding process.

Another sign of the “MI spirit” in action? The last of the regular virtual sessions was entirely run by the internal sustainability team.

Next steps for the Northwest ATTC team include working with Connections staff to identify recommendations for ongoing sustainability of MI support and training to staff.

NIATx: Promising Practices to Increase Engagement in Treatment

Maureen Fitzgerald
Great Lakes ATTC/NIATx

NIATx Principle 1, "Understand and Involve the Customer," comes alive when a change team conducts a walk-through of their agency or one of its processes.  For many change teams, the first walk-through focuses on the customer's first contact with the agency: the intake and admission processes.

A walk-through of first contact can start with a member of the change team can pose as a customer calling the agency for information.  This simple activity can uncover previously unnoticed barriers:

  • an out-of-service phone line
  • an endless loop of voicemail prompts
  • a grumpy phone receptionist 
The walk-through can also bring attention to the agency's physical environment. 
  • Is the entrance marked?
  • Are clients welcomed by a friendly staff person or a uniformed security guard?
  • Is the waiting area comfortable and inviting? 
Waiting area, Above and Beyond Family Recovery Center
A welcoming environment that reflects clients' cultures and interests can have a big impact on engagement in treatment. Mark Sanders, LCSW, CACD, cites Above and Beyond Family Recovery Center in Chicago as a great example of an agency that's committed to creating a welcoming environment, as part of a strategy to improve engagement for all of its clients, but in particular for African Americans seeking treatment. Mark recently interviewed Dan Hostetler, executive director of Above and Beyond, for more insights on this agency's commitment to its diverse client population. Read the full story here

Mark will discuss the importance of the agency environment and other strategies to engage African American clients in treatment in the upcoming Great Lakes ATTC webinar:

Engaging African Americans in Substance Use Disorder Treatment
Wednesday, February 5, 2020
11:00am CST

The webinar will be recorded and available for viewing on the Great Lakes ATTC website after the live event. 

Read about other NIATx Promising Practices 

Has your agency conducted a walk-through of one of your processes? What did you discover? Share your story in the comments section below. 

ATTC Region 2: Increasing Capacity for the Drug Courts in Puerto Rico

Tech Transfer in Action

The Institute of Research, Education and Services in Addiction at the Universidad Central del Caribe, School of Medicine has been providing various trainings to the Drug Courts of Puerto Rico. Drug Courts is a program that seeks the recovery of people with substance use disorders through a continuous and intensive judicial follow up. It applies the Therapeutic Justice Model, which is the use of social science to study the extent to which legal rule, or practice promotes the psychological and physical wellbeing of the people it affects. Drug Courts goals are the recovery of the participants, their reintegration to society, and decrease recidivism or commission of new offense. All training opportunities delivered to the Drug Courts personnel have been requested by the Judicial Academy of Puerto Rico. The Academy took the initiative to provide training to all there staff from the Department of Correction and Rehabilitation (e.g., prosecutors, police, officials, social workers, judges, assistants, and program coordinators) who are directly or indirectly involved in Program. This was with the intention that all areas receive the same training (based on evidence and best practices), share the same knowledge and understanding on how to provide adequate and needed services for all Program’s participants.

All trainings provided to Drug Courts staff during past year included the following topics:
  • application and management of incentives and sanctions in specialized courts for controlled substances;
  • access to justice and the treatment of substance use disorders for vulnerable populations
  • trauma management in people with substance use and mental health disorders and the vicarious trauma;
  • instruments for screening and assessment evaluation for substance use disorders; and
  • the effect of opioids on human behavior and its impact on the justice system.

These topics considered the specific capacity building needs from criminal justice personnel. The delivery encompassed increasing knowledge and providing necessary skills for this particular workforce, thus they are able to understand substance use disorders, screening and assessment strategies, connection between substance use and mental health disorders, as well as its treatment alternatives. Raising awareness and capacity building in these professionals will decrease stigma on persons with substance use disorders, while helping them receive needed services and treatment to recover their lives and return to the community with the tools they need to be a productive citizens. It is our goal that we do not only influence the workforce but to create a cascade of actions to reduce health disparities among the population they serve. These professionals now have the skills to assist participants with particular situations while in receiving their services. The Drug Courts program has been in Puerto Rico for 23 years and the NeC ATTC has been providing them with training and technical assistance. This year we delivered a total of 15 trainings and impacted 442 providers. We look forward to continue providing the Drug Courts program with all the trainings they need in order for participants to receive quality and responsive services.

2020 Vision: What Will You Improve in the New Year?

Mat Roosa, LCSW-R
NIATx Coach

With the start of a new year, many organizations resolve to tackle long-standing issues, such as high no-show rates. In this post, NIATx coach Mat Roosa shares his vision for reducing no-shows: Offer walk-in hours.

“The best way to get rid of no-shows for appointments is to get rid of appointments.”
As a coach, I often work with behavioral health organizations that are struggling with low show rates. The result is low staff productivity, reduced revenue generation, client turnover, increased costs associated with higher discharge and admission rates, and a felt failure to perform the core service mission of supporting individuals through the recovery process.

Programs often choose to work on a range of strategies designed to increase show rates. They use incentives for clients and staff, reminder calls, and transportation supports to get more clients to the door at the designated hour. But too often these efforts yield only modest results. That is when I often make the bold assertion above, and usually couple it with the following question:

Why do we think that appointments will work when we are serving people who do not schedule appointments for any other service that they receive?
The introduction of developing a walk-in approach often yields a great deal of anxiety…

  • But we won’t be able to plan our day?
  • We will have no way of knowing who will show up?
  • How will we staff for this?

In response to these concerns, I typically ask a question or two:

  • How do emergency rooms do it?
  • How do grocery stores do it?

This is the moment when many teams began to shift their thinking toward a new paradigm: Maybe we could find ways to reorganize ourselves with walk-ins. Perhaps we could do some short walk-in periods during the week to explore the model. Maybe this will create better service access. If a grocery store can do, we can too.

Walk-ins don’t work for everybody, but they do work for many. And they are a great way for traditional programs to rethink how they deliver care.

See the NIATx Promising Practice: Establish Walk-in Hours

About our Guest Blogger Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in the areas of quality improvement, organizational development, and planning, evidence-based practice implementation. He also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat at


By The New England ATTC and Stephen Andrew, LCSW, LADC, CCS, CGP 

The New England ATTC is collaborating with the Health Education & Training Institute in an effort to implement Motivational Interviewing (MI) systems-wide throughout Tri-County Mental Health Services of Maine. Tri-County Mental Health Services provides integrated behavioral health care for clients with substance use and mental health problems, and they are seeking to integrate MI across their entire continuum of care. MI is a client-centered, evidence-based method for enhancing clients’ intrinsic motivation to change. It was selected as the focal intervention because of its potential to improve client engagement, retention, and substance-related treatment outcomes. The goal of this MI initiative is to optimize sustainability within the organization by creating an internal group of trainers and coaches who will learn to use and teach/coach MI.

The intensive technical assistance (TA) initiative is targeted towards counselors, supervisors and community workers with varying levels of experience in MI and will ultimately be delivered across 5 Tri-County locations in Maine. It begins with three days of face-to-face instruction followed by a virtual MI Master Class using Zoom conferencing. The Master Class provides continued coaching and skill building. Additionally, there are on-going monthly Zoom calls for core staff over a 12-month period and assigned MI activities to practice concepts during existing staff meetings.

On-site trainings are conducted by Stephen Andrew, LCSW, LADC, CCS, an internationally renowned MI and MIA-STEP (Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency) trainer, and long-standing member of the International Motivational Interviewing Network of Trainers (MINT). Stephen has been a consultant and trainer for the New England ATTC since 2007.

During the first two days of face-to-face training, Stephen provides an introduction to the clinical method of MI with a focus on intervention basics. Participants have the opportunity to explore creative ways of integrating MI techniques and skills. After orientation to the underlying spirit, structure, and principles of MI, application of practical exercises helps participants strengthen their empathy skills, recognize and elicit change talk, and roll with resistance.

The third day of training is titled Advancing the Practice using MIA-STEP. MIA-STEP is a training for those that supervise or mentor treatment providers in a clinical setting whose roles involve providing feedback and coaching to help practitioners improve their skills and effectiveness. This training provides clinical supervisors practical tools to enhance treatment providers' MI skills. To date, 25 Tri County Mental Health Services staff have completed the two-day MI basics training and 16 staff have participated in the MIA-STEP one-day training at the first location in Lewiston, ME.

Participants have referred to the in-person trainings, and Stephen, as “amazing” saying, “the whole audience loved it.” When asked which training aspects were most useful, staff indicated they now had “a better way to work with clients who are ambivalent about sobriety,” and “insightful … tools for [their] work ‘tool box’ Further, staff reported feeling better equipped to understand their own “personal shortcomings and … to normalize ambivalence,” ,” to “meet clients where they dream,” and to “sit with clients ambivalence and suffering” until the client felt ready to move forward.

The monthly virtual Master Class is conducted by Kathryn Hartileb, PhD, RDN, an Assistant Professor at Florida International University’s Herbert Wertheim College of Medicine. Kathryn is an expert in health communication and behavior change. Like Stephen, she is a long-standing member of the MINT network. Kathryn’s main goal when leading the Master Class is to build participants’ MI skills through exploration of Bill Miller's "Master Class" exercises and practice diving into the Four Processes of Engaging, Focusing, Evoking, and Planning. The Zoom Master Class is designed to provide the opportunity for participants to practice MI Spirit and skills alongside a supportive network of peers facing similar professional challenges as well as the opportunity to consult about clients who struggle with substance-related concerns. The first Master Class was launched on October 9, 2019, with seven participants in attendance. Classes will continue through September 2020.

The New England ATTC is excited to partner with the Health Education & Training Institute to offer this intensive TA initiative to Tri-County Mental Health Services of Maine!