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Center for Substance Abuse Prevention (US). Addressing Fetal Alcohol Spectrum Disorders (FASD). Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 58.)
Why SAMHSA Created an Implementation Guide as Part of This TIP
Part 1 of Addressing Fetal Alcohol Spectrum Disorders (FASD) provides the tools your clinicians need to begin addressing FASD prevention and intervention with clients. However, an extensive literature review suggests that without specific attention to implementation issues, these tools are likely to go unused or to be used ineffectively (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). This Implementation Guide will help you ensure that the ideas in Part 1 are put into practice in your program or agency in a way that creates value, both for your agency and your clients. Implementation will require the active support of executive administration and the expertise of clinical supervisors.
Much of the guidance provided in this Implementation Guide will be familiar to readers of TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery (Center for Substance Abuse Treatment [CSAT], 2008). TIP 48 provides a useful framework for approaching organizational change, and a significant portion of that framework is reiterated here, but with some important modifications and “tweaks” that are essential to providing FASD-informed services. Another useful resource is SAMHSA's Technical Assistance Publication (TAP) 31, Implementing Change in Substance Abuse Treatment Programs (CSAT, 2009).
Why Address FASD Prevention and Intervention?
The value of screening women of childbearing age in behavioral health settings is clear-cut. For any woman who is or may become pregnant, protecting the health of that pregnancy (or potential pregnancy) is a fundamental health issue for the woman herself. Added to this, alcohol consumption questions are built into most forms of health screening, making exploration of this issue a professional commitment. If pregnant women are part of your client base, ignoring this issue means not fully serving the client.
The case for providing services tailored to individuals who have or may have an FASD may not be as simple, but is equally compelling. The historical perception that an FASD represents permanent brain damage, and thus these people cannot be helped in a mental health or substance abuse treatment setting is only half true: Yes, an FASD does represent permanent brain damage; no, it does not mean that these people cannot be helped, any more than being homeless or involved with the criminal justice system means an individual cannot be helped in these settings.
An FASD is a co-occurring disorder, and needs to be approached from that perspective. Families are seeking this expertise, even if they don't yet know to call it ‘FASD,’ and clients in need of FASD-informed services will continue to appear in your settings. There is an active movement in the mental health field toward a recovery focus and a strengths-based focus, toward meeting clients “where they are.” This movement is growing in the substance abuse treatment field, as well, as are the trauma-informed and family-centered care movements. An individual who has or may have an FASD fits perfectly into any of these paradigms. Individuals with an FASD do want to recover, whether in substance abuse or mental health treatment; they do have strengths; they do experience trauma (at higher rates than the general population); they do have families; and, as with any other client, they are capable of responding positively when treatment is tailored to their unique needs.
The Effects of FASD on Recovery
At the same time, it cannot be ignored that clients with an FASD are likely to experience challenges to successful treatment above and beyond those experienced by clients who do not have one of these disorders. The client with an FASD may have difficulty in any or all of the following areas:
- Remembering program rules or following multiple instructions.
- Remembering and keeping appointments.
- Making appropriate decisions by themselves about treatment needs and goals.
- Appropriately interpreting social cues from treatment professionals or other clients.
- Attending (and not disrupting) group activities.
- For those accessing substance abuse treatment, staying substance-free after treatment.
- Interpreting or understanding complex meanings of language or information.
The combination of some or all of these factors may lead a counselor to assume that an individual with an FASD is resistant to treatment (and this assumption is often made). It is essential that staff be able to discriminate between a symptom of an FASD and actual treatment resistance. Clients with an FASD may fully intend to be compliant with treatment and want to do well in recovery, but lack the skills and understanding from the provider to help them meet their unique challenges while participating in a recovery program.
The Benefits to Your Program of Addressing FASD Prevention and Intervention
A growing body of evidence is demonstrating that interventions with individuals with an FASD can be effective, that this population can and does succeed in treatment when approaches are properly modified, and that these modifications can lead to reduced stress on family/caregivers as well as providers (Bertrand, 2009). Moreover, in a study of 1,400 patients with prenatal alcohol exposure, Astley (2010) found that 9.3 percent presented with no central nervous system (CNS) dysfunction, despite alcohol exposure levels as high as the 10 percent that did receive a diagnosis of FAS. The one factor that significantly differentiated the children with no CNS dysfunction (no evidence of learning or behavior problems) from those with full FAS was a stable, nurturing home environment with intervention services.
Addressing FASD also has the potential to enhance the treatment experience for both the individual with an FASD and those around him or her, increase retention, lead to improved outcomes, reduce the probability of relapse, increase engagement rates in aftercare services (alternately referred to as recovery support services), and reduce overall societal costs. In addition to the benefits for the client, addressing FASD as part of your program can potentially lead to increased clinical competence of your staff, an increase in appropriate referrals, increased staff retention, higher levels of staff satisfaction, reduced risk of burnout, and reduced turnover.
Addressing co-occurring disorders is also a key priority for the federal government, state governments, insurance companies, credentialing boards, and accrediting organizations. By starting now to address FASD, you will be better positioned to compete in the future treatment marketplace. Ideally, your agency can become part of the larger community of research practitioners who seek the best ways to help clients more quickly experience a higher quality of recovery. By joining with other agencies in your network, you can coordinate treatment practices and perhaps collaboratively obtain research grants. Many effective treatment practices in both the substance abuse and mental health fields, as in the field of approaches to FASD, are not yet validated through research because agencies do not fully realize the value to the greater treatment community of their unique approaches. However, the body of research around FASD is growing rapidly, and addressing FASD now positions your agency at the front end of an emerging skill area.
Most importantly, addressing FASD provides another possible route to success with a client. Individuals with an FASD are a largely hidden population, yet one that is at an increased risk of presenting in your treatment setting. For every client that did not return for additional appointments, or seemed noncompliant or resistant with no clear explanation of why, or just didn't seem to ‘get it,’ a knowledge of FASD on the part of your staff can be the one additional clue that solves that puzzle and enables success for both the client and the program.
Thinking About Organizational Change
If you have decided to implement some or all of the recommendations in Addressing Fetal Alcohol Spectrum Disorders (FASD), Part 1, you, your staff, your clients, and the other agencies and organizations with which you interact may require the development of new treatment protocols and policies, as well as new clinical knowledge, attitudes, and skills. These changes can be rewarding and/or frustrating. Any change in services or approaches to clients will call for a significant change in organizational culture, but will be beneficial to client well-being in the long run.
The box “Key Elements of Assessment and Planning” summarizes the key elements of organizational assessment and planning for change, topics that are discussed in greater detail in Chapter 2 of this Guide.
Key Elements of Assessment and Planning
The following five areas are critical to organizational assessment and change planning.
| Current status of the organization relative to targeted change goals | Current practices, staff and administrator competencies, policies and procedures, facilities, etc., will need to be evaluated. These are similar to client assessments that determine the nature and scope of a client's issues and challenges as well as their strengths and assets. |
|---|---|
| Past experiences with change initiatives | Just as a bad experience in a previous treatment program may color a client's perception of a new program, old experiences with organizational change may affect attitudes toward new efforts. A thorough review of organizational history of change is critical to planning new organizational change. |
| Ongoing assessment | As in treatment, assessment is not a one-time activity, but rather an ongoing process that includes regular feedback and adjustment of your plans for organizational change and your approaches to facilitating change. |
| Stakeholders of all kinds | Involve as many clients, stakeholders, and community resources as possible (e.g., boards, staff, funders, clients, community representatives, 12-Step groups). These groups function best when they feel involved, and have a key role in determining how to make the recommended changes work best in daily practice (particularly staff). In addition, the plan should speak to what these groups want and what motivates them for the change: If your staff desires professional growth opportunities, change aimed at providing FASD-informed services can be linked to expanding staff capabilities. Similarly, your board's concern with expansion might be tied to the need for increased capacity if the organization is to address FASD among clients. |
| Clinical supervision | No stakeholder is more important than the clinical supervisor commissioned to implement the clinical mission and vision of the administrators. This individual's challenge is to help clinicians maintain a high level of best practices, to oversee the application of these practices, and to conduct process and program evaluation for quality control. Supervision should be more instructive and less crisis-driven—proactive rather than reactive—by using such strategies and resources as:
|
An excellent resource for organizational assessment for change is the Program Change Model discussed by Lehman, Greener, & Simpson (2002; http://forces4quality.org/sites/default/files/Tool2.1Lehman Assessing Agency Readiness for change.pdf), and its accompanying survey, Organizational Readiness for Change (http://www
.ibr.tcu.edu /pubs/datacoll/Forms/orc-s.pdf). Their model addresses strategies and tools for assessing institutional and personal readiness and outlines the stages of the transfer process.
Ultimately, the application of these elements may suggest that the best decision is to delay attempting a change and focus instead on organizational climate and readiness. Introducing organizational change before the groundwork has been laid—much like introducing change to a client when they are not at the right stage of readiness—can hinder later change opportunities. However, if you decide to move forward with a change plan, the box “Key Principles of Implementation” provides information on implementation.
Key Principles of Implementation
Principles for implementing the change plan are directly analogous to principles of treatment and recovery in that both are achieved in steps, making it a process rather than an outcome. The following principles of managing change are directly adapted from principles of care that are relevant to providing effective FASD-informed services.
| There is no single model or approach to providing FASD-informed services, or for implementing a program of organizational change. | A preconception about how change should occur or inflexibility during the change process is likely to be counterproductive to meeting a client's treatment goals or a program's change goals. Constant vigilance and course corrections will be needed, and should be made in consultation with the same stakeholders who developed the original change plan. Periodic focus groups or meetings with staff, clients, and administration provide excellent opportunities for feedback and give all those involved a voice in the process. |
|---|---|
| A belief in your organization's ability to accomplish the change plan is fundamental. | As with counselors, an administrator's belief that change can happen (and the ability to communicate that belief) is a central component of the change process. |
| The change program for an organization should be individualized to accommodate the specific needs, goals, culture, and readiness-for-change of that organization. | Like any treatment plan for an individual who has or may have an FASD, it is critical to adapt and ‘personalize’ the plan to fit specific organizational needs and culture. |
| It's about maintenance. | After implementing an organizational change plan, maintenance of the changes is essential, particularly in the first year or two. Flexibility around incorporating staff and client recommendations is critical to buy-in of the change. Newly learned practices and procedures are fragile and will tend to drift. In addition, organizational change almost always brings about some degree of personnel change, which requires up-front planning for the selection and integration of new employees. Equally important, unforeseen barriers may arise. Regular supervision and training boosters are the best insurance that behavior change will last over time. Even when the changes are institutionalized, however, a commitment to continuous quality improvement will help ensure your program's ability to respond to ongoing changes in the needs of your client population and community. |
The Challenges of Implementation
Any approach to organizational change should assume that resistance may challenge the process. Specific to FASD, some of the usual forms of staff resistance you may encounter are included below, along with suggested responses that may help staff members to see the change process in a more positive light.
It is also useful to remember that resistance can be valuable to a change effort, as it often springs from legitimate needs and/or concerns. By rolling with resistance, you can identify aspects of your change plan that warrant revisiting or revising.
At the same time, failure to implement new clinical practices often has little to do with resistance to change on the part of staff.
Addressing resistance directly will lessen the likelihood that opposition will spread and influence others.
- ATTC Change Book, 2nd Edition, p. 27
Failure to implement can be a result of issues such as inadequate modeling from administration, lack of follow-through, inadequate training, and many others. Even the best counselors and administrators are highly constrained by the contexts in which they work. Accordingly, implementation success requires administrators to 1) be proactive in making the new practice fit the context, and 2) create an organizational climate that encourages and supports implementation.
| Resistance | Response |
|---|---|
| I haven't learned this. When will I have time to do the training? | All changes in programming require new learning, and FASD will be no exception. However, new learning means new and expanded skill sets, which can positively impact professional development and advancement. I will work with you to adjust your caseload so that the training is possible. |
| How can I tell a pregnant mother not to drink? Her OBGYN/doctor says it's okay. | It is true that some doctors still suggest that the occasional drink is okay. However, the SAMHSA FASD Center for Excellence Web site (www |
| The mother is choosing to harm her baby. | Many women are unaware of the risk of alcohol consumption during pregnancy (see previous statement). In addition, half of all U.S. pregnancies are unplanned, so the mother may not realize the potential harm she's doing. Lastly, if the mother has a problem with alcohol, her ‘choice’ to drink is no more a choice than it is for any other individual in substance abuse treatment. |
| How do I adjust this cognitive abstract program for someone who does not have the ability to understand abstract concepts? | You don't have to abandon the techniques you generally use. The FASD training will show you how to modify treatment for these individuals within the framework of your usual treatment approaches. |
| Why am I making exceptions for this client and not for others? This will require ongoing modification of the treatment plan. | It is better to see modifications to the treatment plan as tailoring rather than ‘making exceptions,’ as tailoring and ongoing modification are a necessary part of meeting clients where they are. |
These two tasks are intertwining: Fitting new practices to your context requires a thorough review of your agency's current operations. Such self-examination, in turn, helps create an organizational climate of openness to new ideas and experimentation. Before implementation begins, it is important to create positive expectations among staff. Investing the time to educate staff, express support for the specific implementations, and explore potential barriers and concerns with staff can go a long way toward creating an environment of operational transparency and ensuring staff acceptance of change, especially in the early stages.
Often, the executive staff faces more immediate resistance or ambivalence because the initial groundwork was not done. Moreover, administrators have likely considered the change ideas for some time and expect staff to be at a similar level of enthusiasm and commitment to the proposal. Change is easier to make when those involved:
- Understand why the change is needed and the benefits they will realize;
- See how the new ways will integrate into and honor what has been done previously; and
- Are given motivation strategies for providing ideas and offers of assistance in implementation.
Maximizing the Fit
For a clinical innovation to take hold, it must fit with:
- Key characteristics of your target population and community (e.g., values, expectations);
- The skills, licensures, certifications, and team structures of your staff;
- Your program or agency's facilities and resources;
- Your policies and practices;
- Local, state, and federal regulations;
- Available interagency networks (e.g., needed outside resources, memoranda of understanding); and
- Your reimbursement procedures.
Certain kinds of mismatches will impede change. For example, no one would expect successful implementation of an innovation when staff lacks the skills to perform it. However, something as seemingly trivial as a lack of appropriate space or needed audiovisual equipment can also stall an innovation. As with many endeavors, the details are critical.
It is likely that adjustments will be needed both in your agency or program's context and in the ways that the recommendations presented in Part 1 are implemented. Part 2, Chapter 2 of this TIP provides procedures, checklists, and other tools for assessing the fit between the recommendations provided in Part 1 and your program or agency's current context, procedures, and so on. Useful though these materials are, your ultimate success in “maximizing the fit” will depend on creativity, problem-solving skills, and determination and patience in applying them.
The Stages of Organizational Change
Change in a program, just like change for a client, occurs in stages. In the early stages of implementing the recommendations in Part 1, organizations will profit from a climate that promotes:
- A willingness to take risks and try unconventional approaches;
- A willingness to tolerate some ambiguity as the fit between new practices and context evolves;
- An ability to recognize false starts and to abandon approaches that are not working;
- Transparency and inclusion when pursuing change; and
- Appreciation and reward for ideas and implementation.
As noted earlier, the later stages of implementation will be facilitated by:
- A commitment to continuous quality improvement;
- The development of structures that support and reinforce the change (e.g., standardized training for new staff, and continuing education and supervision for all staff);
- Expressions of organizational pride in accomplishment; and
- Institutionalization (in which new practices become everyday practices).
The Role of the Administrator in Introducing and Supporting New Clinical Practices
Chapter 2 of this Implementation Guide presents the tasks you will need to accomplish to implement the changes elaborated in Part 1. Important as these tasks are, successful implementation will ultimately depend on the leadership you provide as they are carried out. The box, “Key Elements of Leadership,” provides a summary and leads directly into the more detailed discussions of Chapter 2 of this Implementation Guide.
Key Elements of Leadership
| Commitment | If you and your administrative colleagues are not fully committed to making your agency's services more FASD-informed, meaningful change is unlikely to occur. In many ways, attempting change without the commitment of organizational leaders can be worse than no attempt to change at all. Staff will eventually “figure it out” if leaders are only giving lip-service to a new idea. This perception will undermine the current attempts at innovation and may lead to a staff that is reluctant to try new ideas. |
|---|---|
| Vision | Leadership means having a vision of how the organization will change. This vision should include explicit goals and a clear statement of how conflicts with other organizational goals will be resolved. However, a vision is more than a list of goals. It is a picture of how the organization will look when change has been accomplished—a picture you must paint with words. Developing this vision and the means to communicate it throughout an agency requires effort. |
| Knowledge | Leadership should include skilled and competent clinicians trained in mental health and/or substance abuse treatment who can direct and supervise services for clients with FASD-related issues. These clinicians should know and appreciate the specific roles that can be played by speech-language pathologists, occupational therapists, licensed social workers, psychologists, physicians, and other behavioral health professionals that are part of a comprehensive network of care for individuals who have or may have an FASD. They should also have an appreciation for the role that FASD can play in interfering with treatment. |
| Inspiration | Inspirational leaders communicate confidence in the organization's ability to change, enthusiasm and optimism about the change process, and an unwillingness to accept failure. This must be communicated to all stakeholders including current and potential clients, funders, board members, staff, community leaders, community 12-Step participants and programs, and sister agencies. Inspiration not only is a process of oral and written communication, but also involves modeling the attitudes and values you want staff and other stakeholders to adopt. Inspiration also involves getting your hands “dirty;” struggling alongside staff in the day-to-day tasks of making new ideas work. |
| Appraisal | Finally, leadership means an ongoing and honest appraisal of progress. As noted above and discussed further in Chapter 2, implementing the recommendations from Part 1 of this TIP will require ongoing assessments of progress, including regular formative evaluation of process and outcomes. Periodic reports on how the organization is doing can and should be developed from the assessments and evaluations. These reports should be shared with staff, as should plans for corrective action (when needed). The most effective leaders frame both good and bad news in a positive light; e.g., emphasizing the learning value of challenges and setbacks and reminding staff that it is the organization as a whole, rather than any individual, that is responsible for making change happen. This means that “we still have room to improve” is preferable to “you still have room to improve.” |
- The Administrative Response to FASD in Behavioral Health Settings - Addressing F...The Administrative Response to FASD in Behavioral Health Settings - Addressing Fetal Alcohol Spectrum Disorders (FASD)
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