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Chestnut Health Systems-Bloomington Adolescent Outpatient (OP) and Intensive Outpatient (IOP) Treatment Model

The Chestnut Health Systems-Bloomington Adolescent Outpatient (OP) and Intensive Outpatient (IOP) Treatment Model is designed for youth between the ages of 12 and 18 who meet the American Society of Addiction Medicine's criteria for Level I or Level II treatment placement. The Bloomington model incorporates OP and IOP programs and is based on a blended therapeutic approach, drawing on four theoretical frameworks (Rogerian, behavioral, cognitive, and reality) for behavioral and emotional change. The program emphasizes an individualized treatment plan that includes the family unit as well as the adolescent.

The two primary treatment approaches in this model are skill-building and counseling groups:

  • Skill-building is offered in a group format and covers 14 different topics weekly. Topics include relapse prevention, life skills, self-esteem, family issues, recovery lifestyle, and recreation/leisure. Assignment to the number and type of skill-building groups is based on an individualized master treatment plan for each adolescent. Each type of group is composed of at least 12 different presentations that are 35-40 minutes long and repeat in a continuous cycle.
  • Group counseling sessions provide an opportunity for adolescents to discuss personal issues in a group format. Adolescents are encouraged to focus on how they can effectively deal with problems and issues in their lives, with peers providing feedback and relating the issues discussed to their own personal experiences. Group counseling sessions occur weekly and are 35-40 minutes long.

Group sessions are offered both in the evening and in the morning to accommodate adolescent school and work schedules. All staff members who provide direct services to adolescents are licensed (e.g., licensed clinical professional counselor, licensed clinical social worker), certified (e.g., certified alcohol and drug counselor), or working toward licensure or certification, which must be obtained by the end of their second year of employment. The Chestnut-Bloomington OP/IOP Program is offered at various dose levels with different components depending on the needs of the individual client.

Descriptive Information

Areas of Interest Mental health treatment
Substance abuse treatment
Co-occurring disorders
Outcomes Review Date: May 2012
1: Abstinence from alcohol and other drugs

Review Date: June 2007
1: Substance use
2: Substance-related problems
3: Recovery environment
Outcome Categories Alcohol
Drugs
Family/relationships
Treatment/recovery
Violence
Ages 13-17 (Adolescent)
18-25 (Young adult)
Genders Male
Female
Races/Ethnicities Black or African American
White
Race/ethnicity unspecified
Settings Outpatient
Correctional
Home
School
Other community settings
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History The Chestnut-Bloomington OP/IOP Program was developed over a 14-year period, beginning in the late 1980s, in a practice setting to address the needs of adolescents with substance use problems. The program is part of a comprehensive system of services for adolescents aged 12-18 that also includes residential care (30-90 days), recovery home, day treatment, early intervention, and aftercare services. The number of sessions and length of stay in the OP/IOP setting are based on an individualized master treatment plan and the adolescent's response to treatment. Chestnut-Bloomington program staff members have developed linkage agreements with more than 80 area agencies, including hospitals, schools, the criminal justice system, child welfare, and other community institutions involved with youth. The largest referral source is the criminal justice system. Adolescent services also include the placement of student assistance program specialists in schools within a county. The Chestnut-Bloomington OP/IOP Program serves between 150 and 200 youth each year.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: May 2012

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Godley, S. H., Garner, B. R., Passetti, L. L., Funk, R. R., Dennis, M. L., & Godley, M. D. (2010). Adolescent outpatient treatment and continuing care: Main findings from a randomized clinical trial. Drug and Alcohol Dependence, 110(1-2), 44-54.  Pub Med icon

Supplementary Materials

ACC Case Manager Individual Service Log

Dennis, M. L., Funk, R., Godley, S. H., Godley, M. D., & Waldron, H. (2004). Cross-validation of the alcohol and cannabis use measures in the Global Appraisal of Individual Needs (GAIN) and Timeline Followback (TLFB; Form 90) among adolescents in substance abuse treatment. Addiction, 99(Suppl. 2), 120-128.  Pub Med icon

Global Appraisal of Individual Needs-Initial (GAIN-I)--Bloomington Core Version [GVER]: 5.4.1

Global Appraisal of Individual Needs-Monitoring 90 Days (GAIN-M90)--Bloomington Core Version [GVER]: 5.4.1

Godley, S. H., Risberg, R., Adams, L., & Sodetz, A. (2003). Chestnut Health Systems' Bloomington outpatient and intensive outpatient program for adolescent substance abusers. In S. J. Stevens & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study (pp. 57-80). Binghamton, NY: Haworth Press.

Outcomes

Outcome 1: Abstinence from alcohol and other drugs
Description of Measures Abstinence from alcohol and other drugs was measured with the Substance Frequency Scale from the Global Appraisal of Individual Needs (GAIN). At intake to the study and at 3, 6, 9, and 12 months after intake, participants were asked about the number of days of use of alcohol and other drugs (i.e., cannabis, crack/cocaine, and heroin/opioid use) during the past 90 days. The percentage of days abstinent from alcohol and other drugs in the past 90 days was calculated from the responses.

GAIN responses were supplemented by electronic staff service logs and on-site urine samples, which were collected and analyzed for cannabis and cocaine at the time of informed consent (i.e., intake) and at 3- and 12-month follow-up assessments. If the urine test was positive but the participant reported no days of drug use, the participant report was recoded as nonabstinent, resulting in a decrease in the percentage of days abstinent.
Key Findings In a randomized clinical trial, participants with substance use disorders were assigned to one of four active treatment conditions: the Chestnut-Bloomington OP/IOP Program, the Chestnut-Bloomington OP/IOP Program with Assertive Continuing Care (ACC), the Motivational Enhancement Therapy/Cognitive Behavior Therapy-7 session model (MET/CBT7), or MET/CBT7 with ACC.

The average percentage of days abstinent from alcohol and other drugs in the past 90 days was higher at each follow-up assessment than at intake for participants in all four treatment conditions (p < .01). However, the average increase in the percentage of days abstinent across follow-up assessments relative to intake was higher for participants in the two Chestnut-Bloomington OP/IOP Program conditions than for participants in the two MET/CBT7 conditions (p < .01); this group difference was associated with a very small effect size (Cohen's f = 0.08).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent)
18-25 (Young adult)
76% Male
24% Female
73% White
14% Race/ethnicity unspecified
13% Black or African American

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Abstinence from alcohol and other drugs 3.8 3.0 3.5 4.0 3.1 3.7 3.5

Study Strengths

The GAIN is widely used with adolescent populations in OP and residential settings and has strong psychometric properties. Internal consistency is high for the GAIN's main scales (Cronbach's alpha value of .90) and moderate to high for its subscales (Cronbach's alpha values of .70 or more). In addition, the GAIN's test-retest reliability for a 48-hour window of alcohol and cannabis use among OP adolescents is acceptable (correlation coefficient of .74). The GAIN has convergent validity with Form 90. Urine testing for cannabis and cocaine has strong reliability and validity, with a long history of use in forensic settings. There was moderate convergent validity of participant self-report of cannabis use with urine test data at study intake and at 3- and 12-month follow-up assessments. The intervention is manual driven, and intervention fidelity was supported by weekly clinical supervision sessions and staff meeting discussions, with corrective action as needed; a clinical competency skills checklist, which was completed by supervisors for clinicians after 3 months of employment and annually thereafter; peer review of performance improvement data; and supervisor review of therapeutic activity session data, which implementing clinicians were mandated to record. There were very little missing data (<10%) for each treatment condition across follow-up assessments. Random assignment controlled for many potential confounds. An appropriate intent-to-treat analytic approach was coupled with sophisticated, mixed-effects repeated measures statistical modeling, which used a restricted maximum likelihood approach by condition to incorporate missing data and test the effects of time and condition, as well as the time-by-condition interaction. The inclusion of effect sizes for between-group differences added to the strength of the statistical analysis.

Study Weaknesses

No reliability and validity data were presented for the GAIN when used for drugs other than alcohol and cannabis. The nonrandom, unobserved collection of urine samples could have negatively impacted the validity of the urine test data. The outcome effect may have been confounded by three issues: (1) the study did not include a no-treatment control group; (2) the research staff conducting assessments and the therapists delivering the intervention were not blind to the assignment of treatment condition, with some of the staff providing treatment to participants across conditions owing to insurance requirements; and (3) a high percentage of participants (73%) were involved in the juvenile justice system. There was no correction in the alpha rejection level for multiple statistical contrasts.

Review Date: June 2007

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Godley, S. H., Jones, N., Funk, R., Ives, M., & Passetti, L. L. (2004). Comparing outcomes of best-practice and research-based outpatient treatment protocols for adolescents. Journal of Psychoactive Drugs, 36(1), 35-48.  Pub Med icon

Supplementary Materials

Dennis, M., Godley, S. H., Diamond, G., Tims, F. M., Babor, T., Donaldson, J., et al. (2004). The Cannabis Youth Treatment (CYT) study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197-213.  Pub Med icon

Dennis, M. L., Dawud-Noursi, S., Muck, R. D., & McDermeit, M. (2003). The need for developing and evaluating adolescent treatment models. In S. J. Stevens & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study (pp. 3-34). Binghamton, NY: Haworth Press.

Garner, B. R., Godley, S. H., & Funk, R. R. (2002). Evaluating admission alternatives in an outpatient substance abuse treatment program from adolescents. Evaluation and Program Planning, 25, 287-294.

Godley, S. H., Risberg, R., Adams, L., & Sodetz, A. (2003). Chestnut Health Systems' Bloomington outpatient and intensive outpatient program for adolescent substance abusers. In S. J. Stevens & A. R. Morral (Eds.), Adolescent substance abuse treatment in the United States: Exemplary models from a national evaluation study (pp. 57-80). Binghamton, NY: Haworth Press.

Risberg, R. A., & Funk, R. R. (2000). Evaluating the perceived helpfulness of a family night program for adolescent substance abusers. Journal of Child and Adolescent Substance Abuse, 10(1), 51-67.

White, M. K., Godley, S. H., & Passetti, L. L. (2004). Adolescent and parent perceptions of outpatient substance abuse treatment: A qualitative study. Journal of Psychoactive Drugs, 36, 65-74.  Pub Med icon

Outcomes

Outcome 1: Substance use
Description of Measures The Substance Frequency Scale from the Global Assessment of Individual Needs (GAIN-SFS) was used to measure substance use at 3, 6, 9, and 12 months after initial intake to the intervention. Adolescents were asked about the frequency, in number of days over a 90-day period, of any substance use, heavy substance use, problems from substance use, and alcohol, cannabis, crack/cocaine, and heroin/opioid use. On-site urine tests were conducted at the 3- and 6-month follow-up interviews to compare with self-reported substance use.
Key Findings The Chestnut-Bloomington OP/IOP Program was compared with three manual-based interventions that had been previously evaluated in the Cannabis Youth Treatment (CYT) study. The CYT interventions differed with regard to planned number of sessions, theoretical underpinnings, and delivery modality but had very similar outcome patterns. The findings showed that substance use decreased across study participants as a whole in both outpatient programs (p < .05). Although substance use decreased in both programs, the decrease was greater in the CYT group from 3 to 12 months after intake (p < .01). The CYT group also had more severe usage patterns across a number of substance-related measures compared with the Chestnut-Bloomington group at the initial intake interview.
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 3.9 (0.0-4.0 scale)
Outcome 2: Substance-related problems
Description of Measures The GAIN Substance Problem Scale (GAIN-SPS) was used to assess the prevalence of 16 symptoms during the past 90 days. The GAIN-SPS includes symptoms for dependence (based on DSM-IV criteria), abuse, substance-induced health and psychological problems, hiding use, people complaining about use, and weekly use.
Key Findings Substance-related problems as assessed by the GAIN-SPS decreased across study participants as a whole in both outpatient treatment programs (p < .001). These improvements remained stable from 3 to 12 months after the intake interview.
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 3.8 (0.0-4.0 scale)
Outcome 3: Recovery environment
Description of Measures Three measures were used for this outcome: (1) the Recovery Environment Risk Index (RERI) scale, (2) self-help participation, and (3) family problems. The 12-item RERI scale includes self-reported days of support group attendance, homelessness, living with alcohol or drug use in the home, violent arguments, and physical, emotional, or sexual abuse in the last 90 days. Self-help participation was the number of self-reported days out of the past 90 spent attending self-help group meetings such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, or Social Recovery. Family problems were also assessed by the number of days out of the past 90 the adolescent reported getting into trouble at home or with family members for any reason.
Key Findings Overall, participants in the intervention (Chestnut-Bloomington) and comparison (CYT) program showed a decrease in recovery environmental risk factors as measured by the RERI (p < .001). However, at 3 to 12 months after the intake interview, recovery environmental risk factors continued to decrease in the Chestnut-Bloomington participants, while remaining virtually unchanged for the CYT group.

Overall, the number of days Chestnut-Bloomington participants attended self-help meetings increased in the 3 to 12 months after the intake interview, compared with almost no change for self-help attendance in the CYT participants (p < .01). But there was another interaction between the two treatment conditions such that self-help meeting attendance at 9-12 months decreased in the Chestnut-Bloomington participants, while continuing to remain unchanged in the CYT participants (p < .01).

Family problems decreased across study participants as a whole in both outpatient treatment programs (p < .001) and continued to decrease 3 to 12 months after initial intake for both Chestnut-Bloomington and CYT participants (p < .001).

Emotional problems decreased across study participants as a whole in both the Chestnut-Bloomington and CYT groups (p < .001) and continued to decrease 3 to 12 months after initial intake for study participants in both groups (p < .001), although the decrease was greater among the Chestnut participants (p < .05).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent) 75% Male
25% Female
81% White
12% Black or African American
7% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Substance use 4.0 4.0 4.0 4.0 3.3 4.0 3.9
2: Substance-related problems 4.0 3.5 4.0 4.0 3.3 4.0 3.8
3: Recovery environment 3.7 3.3 4.0 4.0 3.3 4.0 3.7

Study Strengths

The Global Appraisal of Individual Needs (GAIN) and the Recovery Environment Risk Index (RERI) are widely used, and the investigators went to great lengths to psychometrically evaluate these measures. Psychometrics ranged from very good to excellent. Available evidence suggests the measures used to assess outcomes are valid indicators of the constructs being measured. The research protocol included extensive attention to methods of ensuring treatment adherence and treatment comprehension, and the methods were well implemented in the studies. The approach to missing data, which was essentially full information maximum likelihood, was nearly optimal in this case and represented the state of the science. The design was rigorous. The analysis was state of the science and entirely appropriate for the study. While not specifically noted, it appears that evaluators were separate from the counseling staff, which would enhance the validity of the self-reported data.

Study Weaknesses

There was a single-item score (number of days) for school problems, family problems, and self-help. Random assignment to the two programs was not included in the design. Reliability was respectable for some of the measures used, but validity is more difficult to assess.

Readiness for Dissemination
Review Date: June 2007

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Godley, S., Risberg, R., Adams, L., & Sodetz, A. (2002). Chestnut Health Systems treatment manual: Bloomington's outpatient and intensive outpatient treatment model. Bloomington, IL: Chestnut Health Systems.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 2.5 2.5 2.8

Dissemination Strengths

Program materials describe the model in considerable detail. Careful attention is given to the timing of program processes and the amounts of time processes should take. A helpful problem-troubleshooting section is provided. The highly detailed treatment manual could be used for training purposes. Evaluation and tracking tools are provided to support quality assurance.

Dissemination Weaknesses

Some of the items in the treatment manual are specific to this implementation site (Bloomington) and may not be applicable to other implementation sites. No information on available trainings or support resources is provided. Some of the quality assurance tools focus on use of staff time, but it is not clear how this does or should relate to program outcomes.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Treatment manual Free Yes
Telephone consultation Free Yes
Quality assurance materials Included with manual Yes
Contact Information

To learn more about implementation or research, contact:
Susan H. Godley, Rh.D.
(309) 451-7802
sgodley@chestnut.org

Mychele Kenney, M.S., LCPC
(309) 820-3763
mkenney@chestnut.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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