4
Benefits and Challenges of Research Collaboration for Community-Based Treatment Providers

Albuquerque's late afternoon sun slanted through the dusty windows of Scholes Hall at the University of New Mexico. Mick Kirby had waited patiently sitting in an uncomfortable chair throughout the morning in early September and now, finally, it was his turn to share the Arapahoe House story with the Committee on Community-Based Drug Abuse Treatment. He stood and, speaking quietly, described a research and practice collaboration that competes successfully for grants and cooperative agreements, improves services for clients, and facilitates the organization's growth and evolution.

Arapahoe House Comprehensive Substance Abuse Treatment Center opened in 1976 to provide alcohol detoxification and halfway house services for Arapahoe County, Colorado. Over two decades, the center grew to become the largest alcohol and drug abuse treatment program in Colorado. Facilities located in Denver and the four adjacent counties serve residents from throughout the state. Today, Arapahoe House supports a continuum of services for prevention, intervention, and treatment of alcohol and drug abuse and dependence—school-based prevention and intervention services in

This chapter was edited by Victor A. Capoccia with contributions by Gaurdia E. Banister, Merwyn R. Greenlick, Emily Jean Hauenstein, Dennis McCarty, and David L. Rosenbloom. Joseph Westermeyer contributed the "Opportunities for Collaboration" in Appendix I.



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4 Benefits and Challenges of Research Collaboration for Community-Based Treatment Providers Albuquerque's late afternoon sun slanted through the dusty windows of Scholes Hall at the University of New Mexico. Mick Kirby had waited patiently sitting in an uncomfortable chair throughout the morning in early September and now, finally, it was his turn to share the Arapahoe House story with the Committee on Community-Based Drug Abuse Treatment. He stood and, speaking quietly, described a research and practice collaboration that competes successfully for grants and cooperative agreements, improves services for clients, and facilitates the organization's growth and evolution. Arapahoe House Comprehensive Substance Abuse Treatment Center opened in 1976 to provide alcohol detoxification and halfway house services for Arapahoe County, Colorado. Over two decades, the center grew to become the largest alcohol and drug abuse treatment program in Colorado. Facilities located in Denver and the four adjacent counties serve residents from throughout the state. Today, Arapahoe House supports a continuum of services for prevention, intervention, and treatment of alcohol and drug abuse and dependence—school-based prevention and intervention services in This chapter was edited by Victor A. Capoccia with contributions by Gaurdia E. Banister, Merwyn R. Greenlick, Emily Jean Hauenstein, Dennis McCarty, and David L. Rosenbloom. Joseph Westermeyer contributed the "Opportunities for Collaboration" in Appendix I.

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ten elementary, middle, and high schools in Denver and other contiguous counties, seven outpatient clinics located in six communities, case management services for homeless clients, beds for nonmedical detoxification in three facilities, a 32-bed short-term intensive residential treatment program for adults, an 18-bed rehabilitation program for adolescents, and 22 beds of transitional housing for homeless clients in early recovery. Most recently, Arapahoe House entered into a partnership with the University of Colorado Medical School and three additional treatment programs and formed a not-for-profit managed behavioral health care organization that contracts with the State of Colorado and manages drug abuse treatment services for individuals in several geographic areas of the state. Working with research investigators from the University of Denver, Arapahoe House has participated in research and demonstration programs funded by the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, the Center for Substance Abuse Treatment, and the Center for Mental Health Services. As chief executive officer, Dr. Kirby guided the development of the nonprofit corporation and crafted the research collaborations that contributed to the agency's evolution and expansion. He believes in a team approach. Research questions and study design are negotiated in partnership with the investigators. Researchers challenge and clarify clinical thinking and clinicians add practical perspectives. Together, the team identifies and designs the interventions that are most likely to be feasible. Research funds are used to supplement and expand a core staff of five who are responsible for the center's ongoing evaluation and outcome studies. Although Arapahoe House prefers to be the applicant and recipient of research funding (the organization has negotiated a federal indirect rate), Dr. Kirby recognizes that universities are more competitive applicants for some funding. Thus, the applicant organization is usually determined by the nature of the proposal. The relationship with the research team is built on 14 years of collaboration, and the researchers and clinicians have developed substantial mutual trust and respect. They recognize that the collaboration is stronger because of the complementary strengths and abilities.

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OVERVIEW Community-based treatment organizations learn and grow in response to personal and professional experience, education, research findings, established standards and guidelines, city, state or federal mandates, evaluation, observation, trial and error, and technological advancements. They also grow by "opportunity taking and opportunity making," in the words used by a workshop participant in describing her program's success in building a research collaboration to address questions of particular interest to them. This chapter examines the research/practice collaboration from the perspective of the treatment provider. The Arapahoe House story illustrates some of the ways in which this collaboration can contribute both to the scientific basis for drug and alcohol treatment and to the ability of the community-based drug treatment organization (CBO) to deliver treatment. Not every community-based treatment program will have the desire or capacity to emulate Arapahoe House. This analysis assumes, however, that all organizations want to grow and change and, as they evolve, they may find it beneficial to participate actively in the research enterprise. Accordingly, the chapter discusses how to negotiate specific roles and ensure tangible and less tangible benefits from the collaboration. It also examines how organizational culture and stage of development influence the type of research in which a particular CBO is likely to become involved. Appendix I provides some examples of potential collaborative research opportunities, written in a format that would be useful for preparing a document to begin the discussion of a research project of interest to the treatment program. The personal experiences of counselors in recovery have shaped and guided many treatment interventions. Skills and practices were developed primarily on personal learning experiences rather than formal research and have been accepted as essential strategies for successful recovery. However, as the organization and financing of drug abuse treatment becomes more complex and resources become more scarce, payers and consumers are demanding—in this field as well as others—that clinical practice be supported by outcomes data. Successful organizations are developing new ways of learning and responding to the changing environment. BENEFITS AND CHALLENGES OF RESEARCH/PRACTICE COLLABORATIONS The gap separating research from practice is evident from both sides. Researchers observe that many practitioners are slow to adopt findings established by rigorous empirical methods. Practitioners, on the other hand, often perceive research findings as irrelevant to their needs or impractical, if

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BOX 4.1 The Learning Organization Drug abuse treatment programs are not the only corporate entities struggling for survival. Demands for change affect large and small organizations in all settings. For the past decade, chief executive officers and managers have found guidance for corporate change in Peter Senge’s concept of the learning organization, as described in The Fifth Discipline: The Art & Practice of the Learning Organization (Senge, 1990). Senge defines learning in organizations as “the continuous testing of experience, and the transformation of that experience into knowledge—accessible to the whole organization and relevant to its core purpose.” The testing of experience is the essence of the experimental method. Treatment programs that follow this model will be comfortable linking research and practice. not impossible, to implement in their situations. Consequently, bridging the two perspectives by linking research and practice may improve the relevance of research and the effectiveness of treatment and, ultimately, the viability of treatment programs. This integration of practice and research is not without its own challenges. On the one hand, the linkage between treatment organizations and research institutions is neither uniform (there are different types of linkages possible) nor universal (not all CBOs will benefit from a relationship with the research enterprise). On the other hand, the direct benefits of research participation may include staff enhancement and development, as well as financial support for direct and indirect expenses of the research. In addition, programs and consumers may benefit indirectly from access to "leading edge" services and technologies, consumer empowerment, and support for developing an organizational culture and structure that would enhance long-term competitive position. As in any partnership, it is important to clarify the expectations of the potential partners (see Box 4.2). As these questions asked by a program director illustrate, a research project has the potential to become a hidden cost to the treatment provider. Costs of research participation should be covered by research funds. There should be additional benefits for program staff such as access to emerging clinical issues, enhanced opportunities for professional training, and improved information and quality assurance systems. In some cases the opportunity for staff education could extend beyond training, to access to a degree or other credentialing programs offered by a research partner organization. Treatment agencies invited to collaborate with academic research centers should explore the possibility of negotiating tuition remission benefits or a specific number of credit hours (equivalent in value to the costs incurred) for staff development. Other

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BOX 4.2 Chilo Madrid's Ten Questions The challenges for researchers seeking to work with programs that treat alcohol and drug dependence are evident in these questions used by one program to screen researcher requests. Aliviane is an established drug abuse treatment and prevention program serving Mexican-Americans in the El Paso, Texas area. Executive Director Chilo Madrid shared with the IOM committee these questions he has for researchers when they seek access to Aliviane clients and staff. 1.   What funds are available for clinical services? Do all of the grant or contract funds go to research? 2.   Are the researchers sensitive to cultural issues? 3.   Does the study address questions that are applicable to Aliviane or are the research questions unrelated to our work ? 4.   Are the research questions practical? Are hypotheses explained to the program or is the program deceived or unaware of the purpose of the investigation? 5.   How does the treatment or prevention program benefit? What technical assistance or treatment benefits are provided? 6.   Will the research help clients or put them at risk? 7.   What are the long-term benefits for the program and for research theory? 8.   Does the investigator express genuine concern for the program and its clients? 9.   How much choice does the program have in the selection of a specific investigator with whom to work? 10.   If there is to be evaluation, does Aliviane have a say in who is chosen to be evaluator? These questions frame many Of the issues investigators should be prepared to confront :and willing to discuss when seeking a treatment partner. benefits might include data analysis skills enhanced by research participation, skills which can also support management information needs and program evaluation. In addition to covering direct research costs, another financial benefit to the treatment agency could be a contribution to indirect and overhead expenses, similar to that received by universities. The programs should be reimbursed for a portion of overhead, to the extent that the overhead expenses support the research. For example, telephone reception and messaging, intake, parking, and common area spaces, accounting, payroll, security, and advertising all represent some of the indirect costs that support all the functions in the treatment program including research activities. And finally, a program with limited access to capital may benefit from new equipment purchased initially with research funds to support the research.

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Linkages between practice and research and program participation in research can enhance staff pride and esteem and foster consumer empowerment. Staff take satisfaction in their organization's contribution to building practice knowledge as well as improving treatment. For the treatment consumers, a program's participation in research symbolizes its effort to provide the most current treatments. Consumers can also take pride in the opportunity to participate in research initiatives when the research is viewed as relevant to improving their treatment—and when research recruitment is conducted within established guidelines for the protection of research subjects (Code of Federal Regulations, Title 45, Part 46, 1991). Under these federal guidelines, drug abusers are considered a vulnerable population and thus the informed consent process and content are carefully examined by the institutional review board (IRB) with jurisdiction. The knowledgeable and respectful explanation of the study and obtaining of true informed consent can form an important bond between participant and the program. There are a number of ways in which research participation may motivate consumers to participate more actively in the treatment process. However, the most enduring potential benefit to the CBO of a linkage with research may be assistance in building or enhancing a culture of learning, which loosens the grip of dogmatic approaches that are sometimes barriers to adopting demonstrated best practices and bringing new ideas into an organization. FACTORS AFFECTING LINKAGE BETWEEN PRACTICE AND RESEARCH Linkages between treatment providers and research teams can assume many forms, ranging from simply providing access to subjects to becoming full collaborators in the development of research proposals, implementation of protocols, interpretation of data, and publication of results. Collaboration may eventually result in some CBOs developing free-standing research programs, as happened at Arapahoe House. Examples abound of treatment programs that have simply ''hosted" a particular study. Researchers arrive with a funded research protocol and IRB approval, needing only the subjects. For the clinical site, such experiences can be good or bad, depending substantially on the quality of the communication and consideration shown them in the course of the study. The committee heard examples where both communication and consideration failed, even in the context of established relationships, usually because of the failure to understand and appreciate each other's perspective. Few examples were cited of investigations where the research questions start as clinical conundrums brought forward by treatment providers, where treatment staff have roles as co-investigators, and where the goal is the

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BOX 4.3 Practice-Based Research Networks Practice-based research networks provide a model of collaborative learning among providers. Models exist in several branches of medicine, including the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics (Wasserman et al., 1992), the Ambulatory Sentinel Practice Network (ASPN) of the American Academy of Family Physicians (Green at al, 1984; Niebauer and, Nutting, 1994), and the Practice Research Network (PRN) of the American Psychiatric Association (Zarin et al., 1997). These networks are composed of practicing clinicians who collaborate in collecting data and carrying out research, ranging from multi-site clinical trials to the assessment of service delivery mechanisms. Each of these networks has a geographically dispersed national sample of between 700 and 1200 physicians who have agreed to collect clinical and demographic data for the purpose of answering questions relevant to their clinical practice, Including patients' clinical status, treatments provided, and patient outcomes. Such networks provide a natural laboratory for field trials designed to assess methods of disseminating and encouraging the use of practice guidelines and the subsequent effect of guideline use on the delivery and outcome of patient care. development of knowledge to guide change in practice patterns. The practice-based research networks developed in some medical specialties (and described in Box 4.3) do have this goal. They provide the opportunity for those who must implement the research to be represented in setting the agenda and to participate in the research. The partnership between Arapahoe House and their university research partners demonstrates that intimate collaborations are feasible, as do the collaboration models described in the next chapter. However, failure to develop such relationships is not surprising given the lack of research institutions in many communities and the commitment and investment required on both sides to make such a partnership work. University-based treatment researchers are obviously familiar with treatment programs, and they are generally engaged in treatment. But many in CBOs feel that these researchers are often not in touch with the realities of delivering services "on the ground." Some workshop participants suggested that the researchers may ignore the "real clinical issues" when they are not relevant to their research interests as illustrated by the vignette that begins the next chapter. The committee identified a number of variables that appear to interact to affect potential linkages between clinical programs and academically oriented researchers (including those working in nonacademic centers, government, and other applied research settings). These interacting variables—theoretical view of addiction; type of research; research functions and roles,

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as well as stages of organization—are described below in terms of their influence on the opportunities for research collaboration. Theoretical View of Addiction There is no single empirically demonstrated explanation of the cause of drug addiction. Neither is there any single universally accepted theory that explains addiction. Therefore the orientation of the treatment program is the first major determinant of the nature of the relationship between researchers and practitioners. Many treatment professionals view addiction as a biopsychosocial (and perhaps spiritual) condition (Ewing, 1978; IOM, 1990, 1997; Metzger, 1988; Moos et al., 1990; Zucker et al., 1994). This eclectic view has significant implications for theory development and for research. Different weights may be ascribed to the biological, psychological, social, and spiritual dimensions depending on the perspective of the investigator or clinician. If, for example, a researcher is interested in investigating genetic predisposition, then the social-cultural triggers to using drugs, or the psychological and emotional dimensions, will likely remain unexamined. One or a small combination of particular theories forms the underpinning of each treatment research design. Investigations may test (a) a drug to block a receptor, (b) an incentive to change a behavior, (c) knowledge to change understanding, (d) faith to reinforce volition, or (e) the use of vocational rehabilitation to affirm self-esteem. In a parallel, but often less explicit manner, one or more of these orientations also serve as underpinning to treatment programs. Many residential programs are based on reconstructing self-image. Most counseling is based on some combination of behavior modification and self-awareness. Medications like methadone or naltrexone are used to block specific biologic receptor functions. Compatibility between the theoretical underpinning of the research and those of the treatment program is one important ingredient to a successful relationship. Investigators must, first of all, be willing to explore and understand the explicit or implicit theory that guides the program's treatment strategies. If novel theoretical concepts are being tested or introduced, the investigators should be prepared to orient and train management and treatment staff so they understand the research question as well as the intervention and can provide consistent support. Type of Research Linkages between research and treatment enterprises are often impeded by different understanding of what is meant by research. Many researchers think primarily of experimental designs, while the practitioner is more

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concerned with the question of whether or not the treatment worked and what difference it makes to the consumer and the program. The researcher tries to narrow or refine the study questions to obtain statistically significant results. This may require reducing the diagnostic and demographic variation in the study population in order to decrease the sample size required. This approach reduces the cost of the study and perhaps increases its fundability. This methodological rigor has also done much to advance the credibility of clinical research in the drug treatment field. At the same time it has decreased the applicability of research findings to general patient populations. Conflicting with the researcher's desire is the practitioner's need to broaden the research question to be more relevant to the CBO and to more closely reflect the complexity and multidimensional nature of the population it serves. Appendix C provides a comprehensive review of the contributions and limitations of addiction treatment research for community-based treatment programs. At the beginning of the research process, clinicians are uniquely positioned to pose broad questions about the nature of drug and alcohol dependence and the value and variability of different interventions. The questions posed by treatment programs and clinicians may be more directly relevant to treatment personnel than those initiated by an investigator several steps removed from the condition, client, or intervention. As "the research question" is formulated, describing its dimensions becomes a shared domain of the practitioner and researcher. By the time that sufficient understanding is acquired to test hypotheses, the roles may reverse, and the researchers become primary with the treatment personnel taking a more supporting role. Ideally, however, by the time the research study is completed, the treatment providers will have assumed ownership and developed the local expertise necessary to sustain the intervention. Without this "transfer of ownership," a process which works best if it is planned for and programmed into the research phase, there is little likelihood that the research will be adopted into practice (Altman, 1995). Research Functions and Roles Regardless of the type of research, the functions that occur in the research process are the same. Defining the question, developing an explanation, designing a study, gathering information, analyzing findings, generalizing to the next stage, and disseminating findings represent the basic steps in the process. Here too the link between research and practice can be fluid and shifting, requiring some team members be able to cross boundaries. The importance of these boundary crossers (or "bridge people") to the building and sustaining of research/practice collaborations was stressed by a number of workshop participants. Such individuals can operate in

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both the practice and research worlds. In the CBO, the bridge person is the "antenna" of the research endeavor, identifying potential research opportunities in patient trends, service delivery system barriers, and practice needs. In the research setting the bridge person can help ensure that research hypotheses are not too partialized to be relevant to practice, and can facilitate research designs that integrate, not interfere, with the work flow. With the benefit of understanding the treatment context, this person (or two or more people sharing this role) may also help with interpreting findings and facilitating the introduction and adoption of evidence-based approaches to treatment. Clinical professionals, because of their practical experience, have significant knowledge to bring to the formulation stage of the research endeavor. Research professionals, on the other hand, bring significant knowledge to the design phase of research. Data collection lends itself to both domains, while analysis tends to be the domain of the researcher. When it comes to the critical stage of adoption of findings and dissemination for practice, greater involvement of practitioners and consumers is essential for success. Thus, the particular role of the treatment program is defined by the requirements of the research, the experience with research activities, and the clinical circumstances. For example, a passive role might be appropriate when the research design is highly controlled and narrowly focused on a treatment variable such as a new drug that is outside of the expertise of the program and its staff. In other cases program staff may become collaborators in the investigation, including being responsible for specific and subcontracted duties. Finally, a treatment provider could be a principal in the research and share responsibility for all aspects of the study. And some may take the path of Arapahoe House and become full and permanent partners with research organizations or develop professional research components within their own organizations. In all cases, the treatment program should expect to receive appropriate recognition and publication credit for their role in the research project. Stage of Organizational Development and Organizational Culture Community-based drug and alcohol treatment organizations vary in management complexity and the development of management and clinical systems (see Box 4.4). Most organizations begin with relatively simple organizational structures. Management functions and service or production functions are not strongly differentiated. Over time roles and responsibilities become more defined and more complex. This discussion of factors affecting research collaboration includes an examination of the stages of

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BOX 4.4 Stages of Organizational Development Stage I. Rudimentary Stage of Organizational Development The two major determinants of organizational structure in the initial stage of an organization are the environmental pressures an organization faces and the needs of the population within the organization or served by the organization. A relatively simple system emerges in the cooperative response of participants based on their common needs and expectations. Stage II. The Development of Stable Organizational Structures The lack of consistent role performance and effective coordination of roles in a rudimentary organization stimulates the successful organization to create stable organizational structures. This leads to institutionalization of basic roles and the formalization of power structure and organizational hierarchy. The organization's work itself may change as more specialized roles begin to be introduced. Stage III. Highly Differentiated Organizational Structure As the organization grows and responds to complex challenges in the environment a more complex and differentiated organizational structure emerges. Roles and functions become relatively highly specialized and organizational units become differentiated, partly as a result of size, but also as a result of increasing complexity of organizational output. A relatively large and complex organizational form develops in a systematic way out of the less-complex forms. SOURCE: Adapted from Katz and Kahn (1978), pp. 70-76. organizational growth and development because these stages influence the level and type of research in which a CBO might participate. Treatment providers at the first stage of development may not be eager users of, or participants in, research. For other reasons, more developed organizations, whose knowledge and experience in this field is needed by others, may also be reluctant to embrace research. Most organizations, including CBOs, start because a few individuals are drawn together to address a common problem in their environment. They usually reflect both a spatial and social sense of community in the workers and consumers. (See Bowser, Appendix C, for discussion of what creates a sense of community.) At first, there may be few rules or specialized roles to direct their activities. Individual leadership by the founder with a vision often substitutes for procedures and systems. A substantial majority of the community-based treatment providers started this way and many remain at this stage.

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TABLE 4.1 Likely Type of Research Participation of Community-Based Drug Treatment Organizations (CBOs) by Stage of Organizational Development and Nature of Belief System   CBO Organizational Development Stage   CBO Belief System Stage I Stage II Stage III Experience and/or faith Contribute to research questions Respond to surveys Passive research sites (services research) Active research sites (services and treatment research) Scientific Interest in research Contribute to research questions Respond to surveys Active research sites (services research) Full research partners (services and treatment research These relatively simple organizations (referred to as Stage I organizations in Box 4.4 and in Table 4.1) tend to offer one modality of treatment to one type of consumer in one or a few nearby locations. If the organization grows, it does so in ways that minimize risks and uncertainty. While management of such a program matures and roles develop over time, the internal information systems may remain very simple. These organizations are still a very important component of the drug and alcohol abuse treatment community in the United States. For organizations like this, participation in research is likely to introduce uncertainty and risk that can be destabilizing. They typically do not have specialized management, information or training structures. Counselors working in such organizations may receive very limited in-service training. New knowledge is more likely to come from a peer contact, or from individual study and professional development. Therefore, dissemination of new findings for use in these treatment settings must be targeted to the counselors and the consumer community. Historically, important improvements in treatment for mental illness came from better informed and mobilized patients and families pressuring providers to use research findings in their treatments. While small drug treatment providers are not likely candidates for formal research partnerships, they have accumulated knowledge that could improve treatment, especially knowledge about their particular social and geographic communities. When programs progress beyond this relatively simple organizational stage, they may branch out in new but related areas. For example, outpa-

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tient programs that serve men might also develop services for alcoholand drug-dependent women with young children. When organizations become more complex they develop systems to control and coordinate the growing number of pieces of their business. Among the most important new capacities they develop is specialized management for dealing with institutional actors like regulators, payers, and training institutions (Shortell and Kaluzny, 1983). In recent years, some CBOs have expanded through mergers with larger organizations and acquisitions of smaller community-based providers (see Appendix E, Table E-2). These growing entities face financial and management challenges as they absorb and integrate other programs, each of which may have its own culture and community. The information and financial systems often are inadequate, and capital and human resources to fix the problems are lacking. Nevertheless, this emerging group of Stage III community providers are the most likely to be able to absorb research findings and to participate as full partners in the development of new clinical knowledge. However, they may also need special support from regulatory agencies, payers, and even research organizations to realize this potential. For example, Stage III CBOs are likely to be very sensitive to payers' demands for measurable improvements in treatment outcomes. To respond, they may need help in providing staff training and implementing information systems that monitor outcomes. In fact, they may need the same information systems to track their operations that researchers need to follow their clinical interventions. However, without special incentives and support, services will always take precedence over research in clinical settings where management teams are likely to be fully stretched responding to the challenges of growth and change. Another important dimension that mediates a CBO's willingness and ability to engage in research activities is the cultural model defining their "knowledge" about how to treat drug abuse. There are at least two main types of treatment programs in this regard (see Table 4.1). The first group includes programs whose treatment models are based largely on the experiential knowledge of a staff largely comprising people in recovery from drug abuse problems. An example of this would be the drug abuse treatment program built in the tradition of the twelve step programs following the model of AA. The therapists at these programs have come to "know" what it takes to treat the disorder by living with it and they have confidence in their knowledge because it has been tested in what is to them the most important test—their own recovery. Included in this first group of programs are some which are identified with religious organizations. These programs bring an element of faith into their treatment approach. Since faith is built into the foundation of their treatment approach, their religious beliefs fuel their organizational culture,

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including (to some extent) their fundamental "knowledge" about the nature of appropriate treatment for drug abuse problems. The second group are organizations that are related more closely to the general health care system or to the tradition of the behavioral sciences. These treatment programs share more of the culture of the medical sciences or behavioral sciences, including beliefs and values that could be classified as a "scientific" perspective, one that suggests therapists' knowledge about what is appropriate in treatment is defined by the fruits of medical, social, and behavioral research. This same orientation could derive from a program's close affiliation with academia. Research roles and activities, therefore, need to be tailored both to the organization's developmental stage and to its organizational culture. Stage I organizations can contribute to the development of research questions and provide an important perspective that would be missing if research examines only the more complex service delivery systems. It is critical that organizations at all stages participate in surveys of treatment practices, assessments of organizational characteristics, and censuses of patient and workforce descriptions. Stage II and Stage III organizations have the capacity to participate in a greater variety of treatment research, especially in multicenter research projects. Quasi-experimental investigations of treatment practices will also benefit from inclusion of all stages of organizations and greater diversity of treatment populations. Health services research can answer important questions about the distribution of drug users across different types of programs, as well as the ways in which organizational and social policy factors influence pathways to service (Weisner and Schmidt, 1995). Services research can also contribute to the development of services and to assessments of patient outcomes in organizations at developmental Stage II and Stage III. Controlled clinical trials, however, will generally require the management and clinical structures found in Stage III organizations—well-developed information systems coupled with clinicians whose skills and training assure fidelity to experimental protocols. SUMMARY Unique opportunities exist for community-based drug treatment organizations to participate in research at this time of rapid changes in the research, policy, and treatment environments. In fact, much research that is needed can be done only with the participation of treatment providers in community-based settings. Studies of treatment outcomes in the social model residential programs is one such area (Kaskutas, 1998). Needed research, as well as the strengths and limitations of current research for informing community-based treatment are reviewed in a paper prepared for this committee and included in Appendix D and discussed in Chapter 2.

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However, the list of areas where collaboration between treatment and research will improve theory and enhance practice may be almost infinite. The degree of organizational development, the organization's perspective on the basis of treatment knowledge, the type of research, and the type of research participation interact to shape an organization's potential involvement in a research endeavor. While it is not possible to identify specific roles for all community-based organizations in all research activities, it is anticipated that collaboration among CBOs of all types and theoretical orientations will enhance treatment programs and strengthen research. The treatment program's role can be a relatively passive one (for example, contributing to surveys, databases and facilitating access to patients) but they should expect respectful treatment and adequate compensation, as well as to gain knowledge from their participation. Active participation in research requires a greater commitment of staff and agency resources. Clinicians will work with researchers in the definition of research questions and the design of data collection. Management should have an advisory role and the opportunity to review research reports to enhance the interpretation of results. The more advanced organizations are the ones likely to become full partners in treatment research. Such programs may have investigators on staff and have the capacity to serve as principal investigators in research. They will usually have established collaborations with academic or other research institutions and applications for grants will acknowledge their partnership. As their research staff and experience grows, they may become the applicant agency for grants where the source of funding and the area of research makes this appropriate. Some opportunities offered by major gaps between what is know and what is practiced in drug abuse treatment are summarized in Appendix I, Table I-1. Examples of research areas where the treatment program may be the appropriate applicant are also included in Appendix I which describes collaboration opportunities in four areas: 1.   adolescent outreach and early intervention 2.   community reinforcement, 3.   outreach strategies for early intervention and follow-up, and 4.   researching nontraditional interventions. In summary, the dimensions described in this chapter interact to shape the linkages that tie a clinical program to a research endeavor. Such linkages between research and practice should not only result in a research product that is more relevant, and adaptable, but should also provide direct benefits to the treatment program, its staff, and its consumers.

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