Clinical Supervision

CRA + Vouchers should be supervised by a trained professional experienced in substance abuse treatment and behavior analysis. Supervisors provide significant input into treatment plans and all targets for behavior change. One of their primary functions is to keep the treatment focused on cocaine dependence and those problems that directly affect it, because this population presents with many additional problems that may have no direct relationship to cocaine use and can distract the therapist from the task at hand.

Supervisors' style should include a balance of support, feedback, problemsolving, and instruction. They should promote team problemsolving while also making clear that therapists have primary clinical responsibility for their patients' care. Considering that CRA + Vouchers requires an active therapeutic approach that can be effortful, the supervisor must serve as a stable source of support, encouragement, and direction in implementing the treatment plan.

Weekly Clinical Staff Supervision

Weekly group supervision sessions are an efficient way to review cases. These meetings generally last about 2 - 3 hours and cover all new and active cases. During the meeting, therapists update the team on each patient's progress. Specific behavioral targets and goals are set. Supervisors assist therapists in evaluating progress and in revising plans that are not progressing adequately. The supervisor completes the Supervisor's Checklist (exhibit 36) for each patient each week to ensure that progress on all specific treatment goals is reviewed.

New Cases

New cases are presented according to the following guidelines.

• Cases should be staffed in the weekly supervision meetings within 1 week of case assignment.
• It is the therapist's responsibility to see that the following materials are available for the staffing:
  • An overview of the intake notes, including a detailed lifetime history of cocaine and other drug use and the reasons the person is now seeking treatment
  • Other relevant historic or current situation information, such as prior treatment, probation status, other ongoing treatment, and suicidal ideation
  • Scores from the self-tests and assessment instruments used
  • A completed problem list
  • A tentative treatment plan
• Treatment plans should be finalized after the therapist presents the new case and the supervisor and other staff have provided input. If more information is needed, the treatment plan can be finalized during the next supervision meeting.
  • Goals and priorities should be set by the supervisor and therapist in collaboration. Both primary and secondary areas for change should be identified and prioritized. How and whether to use a voucher system should be decided.
  • Goals should be operationalized. The supervisor should assist the therapist in defining goals in concrete, measurable terms so that progress on specific behaviors can be tracked.
  • The supervisor should assist the therapist in determining how to measure and depict progress graphically in each goal area.

Active Cases

Therapists should present each active case, following the format outlined on the supervisor's checklist.

• The therapist should begin by presenting the patient's cocaine urinalysis graph; this underscores the primary focus of treatment. Any recent cocaine positives should be discussed. Procedures to decrease the likelihood of further cocaine use should be suggested and specific behavioral interventions defined.
• Any alcohol or other drug use that is being actively targeted or monitored should be reviewed. Graphs should be shown with urinalysis, breath alcohol levels, or self-report data, and interventions in that area should be reviewed or suggested.
• Any attendance problems should be discussed.
• The primary behavior change targeted, other than drug abstinence, should be reviewed and progress evaluated in graphic form. Any change in goals or new behavioral strategies should be suggested and implemented at this time.
• Up to four other secondary behavior change goals should be reviewed in a similar manner. Any change in goals or new behavioral strategies should be suggested and implemented at this time.
• Once treatment targets are reviewed, any recent crises or relevant clinical issues, such as suicidal ideation or newly identified problem behaviors, should be discussed.

At any point in treatment, treatment goals and behavioral targets can be changed. Changes in goals may be precipitated by -

• Achievement of prior goals.
• Failure to make any progress toward a specific goal.
• Clear indication that the goal is not functionally related to cocaine use. Proposed changes should be discussed and specific revi-sions documented. This process should continue throughout treatment.

Therapists and other staff members should meet daily to briefly (e.g., 10 minutes) inform each other about issues that may require team assistance. CRA + Vouchers requires a team effort, and CTT meetings are used to facilitate and coordinate that approach. Therapists and other clinic staff can enlist one another's help to facilitate patients' behavior change by using their joint resources.

These meetings help keep therapists focused on patients' specific behavior changes and provide a means for group support, problemsolving, and accessing help from colleagues. Additionally, they serve as a prompt for therapists to be proactive in facilitating progress on their patients' goals. CTTs are particularly useful in facilitating continuity of care when therapists are out ill, on vacation, or otherwise unavailable. For example, if a goal of one patient is to complete an application for employment at a particular worksite but his therapist is not available to assist him, another therapist or staff member can volunteer to cover the case and assist in completing the application. Most importantly, CTTs enhance the clinic's ability to provide comprehensive and timely treatment interventions, which are the mainstay of the CRA + Vouchers approach to treating cocaine dependence.

References