The implementation of evidence-based behavior therapies for routine use in addiction care settings remains a challenge. A prominent issue involves fidelity, or clinician capability to skillfully deliver an intervention as intended and thereby offer therapy-exposed clientele an opportunity to approximate the therapeutic outcomes reported in corresponding efficacy trials. If an evidence-based intervention is not delivered correctly, it may not be as effective for clients as it was in the studies that make up its evidence base in the first place.
One widely studied behavior therapy for substance use disorders is contingency management (CM), which involves the use of tangible reinforcers to encourage clients to demonstrate identified behaviors such as session attendance or medication adherence.
This study examined the links between post-training assessment of clinician skills in delivering CM and outcomes for their CM-exposed clients.
Nineteen direct-care clinicians affiliated with one of the community treatment programs in the Pacific Northwest Node of the NIDA Clinical Trials Network were examined, comparing post-training implementation domains (assessed using standardized patients) to a targeted outcome of subsequently CM-exposed clients.
Clinicians’ skillfulness, a behavioral measure of their capability to skillfully deliver the intended CM intervention, was found to be a robust and specific predictor of their subsequent client outcomes.
Analyses also revealed CM skillfulness to:
- fully mediate an association between a general therapeutic effectiveness and client outcome,
- partially mediate an association of in-training exposure to CM and client outcomes, and
- be composed of six component clinical practice behaviors that each contributed meaningfully to this behavior fidelity index.
Conclusions: Study findings offer preliminary evidence of the predictive validity of post-training CM skillfulness for subsequent client outcomes. This suggests an apparent value in providing skills-focused training in CM, and perhaps other empirically-supported behavior therapies.
Skills-focused training does not necessarily preclude trainer use of didactic and discussion elements in CM training curricula, presumably for purposes of enhancing clinician knowledge of core operant conditions principles and practices, as well as to dispel myths and misconceptions that deter adoption readiness. However, current findings provide preliminary evidence to suggest such passive learning strategies are insufficient if the goal of behavior therapy training is to prepare a workforce to effectively implement a new approach.
Citation: Hartzler B, et al. Predictive Validity of Addiction Treatment Clinicians’ Post-Training Contingency Management Skills for Subsequent Clinical Outcomes. Journal of Substance Abuse Treatment 2017;72:126-133.