Journal of Clinical Child & Adolescent Psychology, 37(3), 682–689, 2008 Copyright # Taylor & Francis Group, LLC ISSN: 1537-4416 print=1537-4424 online DOI: 10.1080/15374410802148087
Promoting the Implementation of an Evidence-Based Intervention for Adolescent Marijuana Abuse in Community Settings: Testing the Use of Intensive Quality Assurance Scott W. Henggeler, Ashli J. Sheidow, and Phillippe B. Cunningham Family Services Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina
Bradley C. Donohue Department of Psychology, University of Nevada, Las Vegas
Julian D. Ford Department of Psychiatry, University of Connecticut Health Center
The development and evaluation of effective strategies for transporting evidence-based practices to community-based clinicians has become a research and policy priority. Using multisystemic therapy programs as a platform, an experimental design examined the capacity of an Intensive Quality Assurance (IQA) system to promote therapist implementation of contingency management (CM) for adolescent marijuana abuse. Participants included 30 therapists assigned to Workshop Only (WSO) versus IQA training conditions, and 70 marijuana-abusing youths and their caregivers who were treated by these clinicians. Analyses showed that IQA was more effective than WSO at increasing practitioner implementation of CM cognitive-behavioral techniques in the short-term based on youth and caregiver reports, and these increases were sustained based on youth reports. On the other hand, IQA did not increase therapist use of CM monitoring techniques relative to WSO, likely because of an unanticipated ceiling effect. Both sets of findings contribute to the emerging literature on the transport of evidence-based practice to real-world clinical settings.
This manuscript was supported by grants DA015844 and DA015658 from the National Institute on Drug Abuse and K23MH01889 from the National Institute of Mental Health. We sincerely thank the clinical and research teams including Steven B. Shapiro, Julie Schmidt, the Connecticut Department for Children and Families, Community Solutions, the North American Family Institute, and the Wheeler Clinic for their support in facilitating the success of this project. We also greatly appreciated the feedback that Sharon Foster, Alliant University, provided on an earlier draft of this manuscript. The first author is a board member and stockholder of MST Services, LLC, the Medical University of South Carolina-licensed organization that provides training in MST. Correspondence should be addressed to Scott W. Henggeler, Family Services Research Center, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Suite CPP, P.O. Box 250861, Charleston, SC 29425. E-mail:
[email protected].
During the past several years, cogent analyses by several federal entities (e.g., Compton et al., 2005; Institute of Medicine [IOM], 1998; U.S. Public Health Service, 2000) have concluded that bridging the gap between science and service is a pressing public health priority. Chief among recommended strategies for bridging this gap is the implementation of quality assurance procedures to support the fidelity of interventions being transported to community settings (Bickman & Noser, 1999; Torrey et al., 2001). As noted recently by several investigators (e.g., Simpson, 2002; Sholomskas et al., 2005), however, the relative effectiveness of different training or technology transfer strategies has received little empirical attention. Although several nonexperimental studies (e.g., Mihalic & Irwin, 2003; Miller & Mount,
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2001) have shown that intensive training can improve therapist implementation of substance abuse and violence prevention treatments, few controlled evaluations of the relative effectiveness of different clinical training strategies have been conducted. Nevertheless, findings from the few extant controlled studies (Kelly et al., 2000; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004; Sholomskas et al., 2005) suggest that relatively intensive and sustained training efforts are more successful at enhancing the adoption and implementation of research-based interventions. This study builds on the work of these implementation researchers by comparing the effectiveness of two strategies for transporting contingency management (CM), a well-validated substance abuse intervention (Petry, 2000; Roozen et al., 2004), to several community practice settings treating adolescents with substance abuse disorders. The first strategy, the Workshop Only (WSO) condition, was based on standard practices employed in the adolescent treatment field (e.g., workshop and training manuals) and served as a training as usual control enhanced with access to CM resources. WSO included a 2-day workshop in CM and access to the resources needed to implement this intervention (e.g., manuals, drug screen test kits and supplies, funding for incentives, and access to a CM expert for consultation). In the second strategy (i.e., the Intensive Quality Assurance [IQA] condition), therapists received the same initial workshop training and access to resources as did their WSO counterparts, but ongoing quality assurance procedures were implemented to support the therapists’ delivery of CM. These procedures were based on the intensive quality assurance protocols used in multisystemic therapy programs (MST; Schoenwald, 2008). Two particular features of the study design are pertinent to the central aim of the study. First, the IOM (1998) noted that drug abuse treatment providers working in community settings are often not open to using new treatments and that the introduction of new treatments that conflict with existing models can destabilize the treatment organization and its clinicians. To address the potential confound of participant amenability to using an evidence-based treatment, our study focused on community organizations and the clinicians within these organizations that had already adopted and were implementing an evidence-based practice (i.e., MST). Second, to attenuate problems with adoptability as a potential confound in examining the central aim of this study, CM was selected as the evidence-based practice for adoption. CM was chosen because of its extensive validation (Petry, 2000; Roozen et al., 2004), compatibility with and recent integration with MST in treating adolescent substance abuse (Henggeler et al., 2006), and amenability to adoption
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as an innovation per Rogers’s (1995) conceptual framework. Supporting the amenability of this intervention for adoption, CM is relatively low in complexity, is fundamentally compatible with the MST family-based interventions that therapists were currently providing, can be tried on a limited basis (high trialability), and its results are highly observable (e.g., results from drug screens). In summary, this study evaluated the capacity of an intensive quality assurance protocol to support practitioner fidelity to CM, compared with a briefer standard training protocol. In light of the emerging research base in the area of implementation science (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005), we hypothesized that the IQA system would increase the initial use of CM techniques, based on youth and caregiver reports, and that such use would be sustained throughout a follow-up period.
METHOD Design For conceptual and statistical reasons, this evaluation was segmented into three time periods: baseline, postworkshop, and sustainability. CM implementation measures were collected throughout all time periods. During the 5-month baseline period, clinicians had access to CM financial resources and could use these to facilitate any MST treatment goals, but the practitioners had not been trained in the CM protocols. Following the baseline period, all clinicians were given the CM training materials and attended a 2-day workshop in CM. At the conclusion of the workshop, MST supervisors (n ¼ 5) and their corresponding teams (n ¼ 8) were randomized into the WSO or the IQA condition. Per standard MST practices, each team consisted of two to four clinicians and at least a 50%-time supervisor. MST teams with the same supervisor were randomized together to avoid possible contamination effects (i.e., the IQA condition included training of the supervisor in supporting the CM interventions). During the 4-month postworkshop period, all therapists continued to have access to CM financial resources. In addition, therapists in the IQA condition received ongoing training and supervision in CM, while counterparts in the WSO condition had phone and e-mail access to an expert CM consultant on request. Likewise, during the subsequent 6-month sustainability period, therapists continued to have access to these same CM financial and implementation resources, based on their training condition (i.e., IQA vs. WSO).
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Recruitment of Clinicians and Families The clinicians were consented by the study investigators who made clear that participation in the research would have no bearing on the clinicians’ internal job performance evaluations. When therapist turnover occurred, new clinicians were recruited within a month of their employment. One hundred percent of the clinicians consented to participate in the study, though not all of these therapists referred eligible cases to the study. Throughout all time periods, adolescents with suspected substance use problems and their families were referred by the participating clinicians for possible recruitment into the study. After obtaining permission from the family, the therapist provided the family’s contact information to the research staff. A researcher contacted the family and obtained informed consent from the legal guardian and assent from the youth. If the youth met diagnostic criteria for marijuana abuse or dependence based on the Structured Clinical Interview for DSM–IV (First, Spitzer, Gibbon, & Williams, 1996), the family completed baseline measures. Of 120 families meeting initial referral criteria (i.e., suspicion of substance abuse during the past year), 42 were not consented for a variety of reasons (e.g., youth did not meet diagnostic criteria; caregiver or youth declined to participate), and 8 did not provide sufficiently complete data, leaving a sample of 70 youths and their caregivers for our analyses. Families were compensated $25 for the initial and each subsequent assessment. All consent and research procedures were approved by the Institutional Review Boards at the participating universities and state agencies. Research Procedures
condition. The majority of the therapists were women (83%), with ages ranging from 24 to 55 years (M ¼ 33 years, SD ¼ 8 years). The sample was relatively diverse, with 57% Caucasian, 20% African American, 13% Hispanic, 3% Asian, and 7% of mixed ethnicity. Most held master’s degrees (83%) and 17% held bachelor’s degrees. The IQA and WSO therapists did not differ on these demographic and experience variables, with one exception. WSO therapists were significantly older, t(28) ¼ 2.34, p ¼ .036, than their IQA counterparts.
Youths and caregivers. Seventy families participated in the study: 35 in the IQA condition and 35 in the WSO condition. Youths ranged in age from 12 to 17 years (M ¼ 15 years, SD ¼ 1 year), and 67% were male. The sample of youths was diverse, with 36% Caucasian, 27% Hispanic, 26% African American, 1% Pacific Islander, and 10% of mixed ethnicity. Clinically, all youths met diagnostic criteria for marijuana abuse or dependence during the previous 12 months, and 56% had had previous treatment for mental health and=or substance abuse problems. The average age of caregiver respondents was 40.8 years, 90% were female, and their median level of education was graduation from high school. Forty-six percent of the families were single parent, and 53% had annual incomes of $20,000 or less. Youths and caregivers in the IQA and WSO groups did not differ significantly on these demographic and clinical variables.
TABLE 1 Contingency Management-Therapist Adherence Measure Items Grouped by Technique Domain
Participants
Cognitive-Behavioral Techniques The therapist helped my child think of ways to tell people that he=she does not want to use drugs. The therapist helped my child practice what to do when things or triggers happen that might cause him=her to use drugs or alcohol. The therapist helped my child come up with ways to get out of situations that involve drug use. The therapist helped my child make a list of things or triggers that might cause him=her to use drugs or alcohol. The therapist helped my child practice how to act if someone offers him=her drugs, that is, ways to refuse drugs. Monitoring Techniques The therapist gave negative consequences (punishments) to my child if the drug screen was dirty and positive consequences (rewards) if the screen was clean. The therapist informed me of my child’s drug test results within 24 hours. The therapist tested my child for alcohol or drug use by breathalyzer or drug screen. The therapist made sure I gave a positive or negative consequence for my child’s drug screen results.
Clinicians. Our analyses include data from 30 MST clinicians: 18 in the IQA condition and 12 in the WSO
Note: Caregiver-reported CM-TAM items. Youth-reported CM-TAM items use appropriate substitutions in wording.
Following recruitment, research assistants collected measures of therapist CM implementation from caregivers and youths at monthly intervals for 4 months, which corresponds to the typical duration of MST treatment, or until the family’s treatment ended. The assessment sessions were scheduled at a time and place (usually the family’s home) that was convenient to the families, and caregiver and youth were separated during their respective assessments. Please note that although a particular family might report on therapist CM implementation for 4 months during their treatment episode, data were collected on the therapists from participating families during the longer 15-month study period (i.e., baseline, postworkshop, sustainability).
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Outcome Measure The primary outcome of interest was therapist implementation of CM procedures, which was assessed with the nine-item CM Therapist Adherence Measure (CM-TAM) based on both caregiver and youth reports. The CM-TAM has been developed and validated in three separate studies (see Chapman, Sheidow, Henggeler, Halliday-Boykins, & Cunningham, 2008) using Rasch modeling (Bond & Fox, 2001), and the two hypothesized domains of cognitive-behavioral and monitoring techniques were accurately identified across both caregiver and youth reports. As presented in Table 1, cognitivebehavioral aspects of CM were measured with five items on 4-point scales (1–4), and monitoring aspects were measured by four items on 3-point scales (1–3). The subscales were highly reliable (cognitive-behavioral reliability ¼ 0.89, item separation reliability ¼ 2.3; monitoring reliability ¼ 0.99, item separation reliability ¼ 8.2). Items were averaged within each subscale separately for youth and caregiver informants. Clinical Interventions with Youths and Families This study examined the use of CM procedures by MST therapists. MST. All families in the study received MST, regardless of when they entered the study or whether their clinician received IQA for CM interventions. MST (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) is a comprehensive family- and community-based treatment for adolescents presenting serious clinical problems (e.g., violence, drug abuse), which places them at imminent risk of out-of-home placement, and their families. MST is provided by master’s-level or advanced bachelor’s-level clinicians using a home-based model of service delivery in which treatment is delivered in the family’s natural ecology (e.g., home, school, community). Drawing upon evidencebased intervention strategies (e.g., cognitive-behavioral therapy, behavior therapy, pragmatic family therapy approaches), MST clinicians develop and direct interventions toward ameliorating those individual, family, peer, school, and community factors that are linked with the youth’s presenting problems. MST clinicians usually carry between four and six cases at any one time and are available to youths and families 24 hr a day, 7 days a week. Treatment typically lasts about 4 months. CM techniques. CM interventions have included several variations but always have the common theme of providing concrete rewards for behaviors that are
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incompatible with substance use. The CM components in our study were based primarily on the work of Donohue and Azrin (2001) with adolescents and Budney and Higgins (1998) with adults. As specified in a treatment manual (Cunningham et al., 2003), three components of CM were specifically added to MST in this study: a voucher system that rewarded clean substance screens, a detailed functional analysis of drug use behavior that served as the basis for self-management planning, and protocols for self-management. Consistent with MST treatment principles, the youth’s caregivers were closely involved in the implementation of these CM components. The functional analysis and self-management planning interventions were similar to cognitive-behavioral techniques currently used by the therapists as part of standard MST treatment protocols, and these techniques were tapped by the CMTAM cognitive behavioral scale. The drug use monitoring protocol (i.e., collection of random urine screens, use of vouchers) was more novel to the therapists, and the corresponding techniques were tapped by the CM-TAM monitoring scale. The provider organizations participating in the study, however, often used drug urine screens in their tracking of treatment outcomes for substance abusing individuals. However, the specified linkage of test results with voucher incentives, which was a focus of CM in this study, was not implemented by these organizations. Regardless of training condition (i.e., WSO vs. IQA), each clinician had access to $150 to facilitate treatment goals. Clinicians in the WSO condition could use these funds to facilitate any aspect of MST treatment, including but not limited to CM interventions. Clinicians in the IQA condition were restricted to using these funds only for the CM voucher system. Training Interventions for Therapists Following the 5-month baseline period, all therapists and supervisors attended a workshop on CM, and following the workshop, MST supervisors and their corresponding MST teams were randomized to receive IQA or not. The workshop was conducted by experts in the use of CM procedures with substance abusing adolescents, one of whom was also an MST expert. To prepare for the workshop, 2 weeks prior to the workshop participants were given and asked to review the manual Integrating Contingency Management into Multisystemic Therapy (Cunningham et al., 2003). The workshop followed the content areas described in this manual and included a conceptual rationale for integrating CM into MST, a description of the basic tenets of CM derived from operant conditioning, a review of the empirical support for these tenets, and a review of findings from a randomized clinical trial adapting CM into MST with
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substance abusing juvenile offenders (Henggeler et al., 2006). Building upon this theoretical and empirical foundation, the remainder of the workshop detailed each component of CM including setting up a contingency contract and reward menu targeting marijuana use, conducting a functional analysis of marijuana use, using the results of the functional analysis to develop self-management plans, teaching youth drug refusal skills, and teaching caregivers how to objectively track substance use. The workshop incorporated skill acquisition procedures including a detailed description of each CM component, expert demonstration of the component, participant practice implementing the component via small-group exercises, role-plays implementing a component, and corrective feedback and positive reinforcement. Prior to each role-play, participants were provided an itemized protocol checklist of the CM component. Participants observing the role-play were asked to ‘‘check’’ any steps within each component that were demonstrated during the role-play. Omitted steps were the focus of corrective feedback provided by the CM experts.
The MST quality assurance protocol for supervisors was also augmented to promote their therapists’ use of CM interventions:
WSO condition. Therapists and their supervisors randomized to the WSO condition were provided access to the materials needed to implement CM (i.e., drug test kits, manuals, financial incentives) and phone access to a CM expert for consultation if desired. These therapists and supervisors, however, did not receive weekly and ongoing focused attention and training in CM implementation.
Analyses
IQA condition. For therapists and supervisors randomized to the IQA condition, the CM protocols were integrated into the existing MST quality assurance system (Schoenwald, 2008), which includes four manualized components including treatment, supervision, expert consultation, and organizational support as well as ongoing training (e.g., quarterly booster training) for therapists and supervisors. As such, each therapist who provided CM (a) received weekly expert case consultation on CM cases to facilitate therapist learning and implementation of CM interventions, (b) had the improvement of CM skills and competencies incorporated into existing clinician development plans, and (c) received quarterly booster training that focused exclusively on therapist practice and role-play of CM components. Across the quality assurance components, consultation focused primarily on identifying and problem-solving barriers to CM implementation, answering therapist questions regarding implementation problems, and providing constructive feedback and positive reinforcement (i.e., praise) for CM component utilization and adherence.
1. Supervisors were asked to have their therapists practice CM implementation during regularly scheduled MST group and individual supervision sessions. 2. Supervisors were taught how to use CM protocol checklists (i.e., a step-by-step breakdown of each CM component) and to provide therapists with specific feedback regarding their implementation of CM components. 3. Supervisors were asked to review session audiotapes of therapists implementing CM components and problem solve any barriers to implementation. 4. Because supervisors audiotaped their CM supervisory sessions, they were given feedback on their efforts to improve therapists’ adherence to CM protocols. 5. Each supervisor had, as part of his or her supervisor development plan, goals specific to CM supervision and implementation.
An essential feature of the data is the nesting of months and families within clinicians, reducing the independence among individual observations. Random regression models (RRMs) were conducted to account for the variance attributable to the nested data structure and to permit the prediction of change over time (i.e., Level 1), for multiple youth and caregiver reports (i.e., Level 2), by the clinician-level (i.e., Level 3) predictor of training condition. Analyses were performed using Hierarchical Linear and Nonlinear Modeling software (HLM 6; Raudenbush, Bryk, Cheong, & Congdon, 2004). Separate three-level RRMs were conducted to evaluate youth and caregiver reports. Further, separate RRMs were conducted to evaluate the two time frames of interest: the baseline to 4-month postworkshop period and the subsequent 6-month sustainability period. Although all time points could have been analyzed in a single trajectory, the postworkshop and sustainability time periods were evaluated separately to ensure that initial spikes in behavior following the workshop were not concealed by the overall trajectory of change. Linear and quadratic trajectories for cognitive-behavioral and monitoring techniques were evaluated (at Level 1). Condition was entered at the clinician level (Level 3; WSO coded as 0), whereas family was included at Level 2 to account for nesting of multiple reports. Time was coded as the study month (converted to orthonormal orthogonal polynomials) rather than the family’s time point so that the Condition Time interaction effects would evaluate the change in clinician behavior over the course of the
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study instead of the change within specific family treatment episodes.
RESULTS The essential questions of the study were as follows: (a) Did the workshop increase use of CM cognitive-behavioral or monitoring techniques, and did IQA enhance this effect? (b) If use of CM techniques increased following the workshop, were these gains sustained? (c) Were observed training effects similar from both the youth and caregiver perspectives? Change in Clinician use of CM Cognitive-Behavioral Techniques As shown in Figure 1, starting at baseline scores of about 2.25 on a 4-point (1–4) scale, significantly different linear trajectories were observed for youth reports of therapist use of CM cognitive-behavioral techniques from baseline through the 4-month postworkshop period (c ¼ 0.25, SE ¼ 0.09, p ¼ .01). Youths reported that therapists in the IQA condition increased their use of CM cognitive-behavioral techniques (c ¼ 0.21, SE ¼ 0.08, p ¼ .02), whereas WSO counterparts showed no significant overall change in such use (c ¼ 0.05, SE ¼ 0.06, ns). As displayed in the figure, both trajectories contained significant curvature (c ¼ 0.26, SE ¼ 0.09, p ¼ .01) that did not differ between groups. This significant initial increase in cognitive-behavioral scores for practitioners in the IQA condition resulted in a significant between-groups difference in scores by the 4th month postworkshop (intercept c ¼ 0.78, SE ¼ 0.36, p ¼ .04). Further change was not evident throughout the 6-month sustainability period (linear trajectory c ¼ 0.12, SE ¼ 0.14, ns). Thus, based on youth reports, the IQA produced a lasting increase in therapist use of the cognitive behavioral aspects of CM.
FIGURE 2 Predicted values for baseline through 4 months postworkshop (post-WS) change in clinician use of contingency management cognitive-behavioral techniques as reported by caregivers.
As depicted in Figure 2, the IQA and WSO groups differed significantly in their linear (c ¼ 0.79, SE ¼ 0.30, p ¼ .01) and quadratic (c ¼ 0.18, SE ¼ 0.09, p ¼ .04) trajectories for caregiver reports of therapist use of CM cognitive-behavioral techniques from baseline through the 4month postworkshop period, with baseline scores of about 2.5 on the 4-point scale. Therapists in the IQA condition initially increased their use of cognitive-behavioral techniques but returned to just above their baseline level by the 4th month postworkshop. Conversely, caregivers reported that therapists in the WSO condition had a slight decrease in use of cognitive-behavioral techniques but returned close to baseline by the 4th month postworkshop. Analyses to examine sustained effects through the 6-month sustainability period resulted in no significant between-groups difference by the 5th month postworkshop (intercept c ¼ 0.05, SE ¼ 0.54, ns), and no further change emerged during the follow-up period (linear trajectory c ¼ 0.21, SE ¼ 0.47, ns). Change in Clinician use of CM Monitoring Techniques Based on youth reports, use of the CM monitoring techniques showed no change from baseline through the 4month postworkshop period, with scores of approximately 2.5 on the 3-point (1–3) scale for both the WSO and IQA conditions (c ¼ 0.03, SE ¼ 0.04, ns). Likewise, caregiver reports on therapist use of monitoring techniques showed no change from a baseline of about 2.25 for both the WSO and IQA conditions (c ¼ 0.09, SE ¼ 0.10, ns). Consequently, analyses of sustained change were not conducted for these indices.
DISCUSSION FIGURE 1 Predicted values for baseline through 4 months postworkshop (post-WS) change in clinician use of contingency management cognitive-behavioral techniques as reported by youths.
The demonstrated capacity of the more intensive quality assurance system to increase the implementation of CM
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cognitive-behavioral techniques among therapists in real-world practice settings is consistent with, and contributes to, the emerging research on the transport of evidence-based substance abuse interventions. Three recent studies with adults (Kelly et al., 2000; Miller et al., 2004; Sholomskas et al., 2005) have contrasted the effects of different clinician training or technology transfer strategies, and each has found that the more intensive strategy produced greater implementation of the evidence-based practice. To the best of our knowledge, our study is the first to evaluate the effects of training strategies on the implementation of an adolescent treatment and the first to evaluate the perspectives of the actual real-world clients being served by the therapists. On the other hand, neither the workshop nor the IQA intervention seemed to influence therapist implementation of CM monitoring techniques based on caregiver and youth reports. A viable, but unanticipated, explanation for this finding was a ceiling effect. CM baseline monitoring scores were high from both caregiver and youth perspectives (i.e., M ¼ 2.25 and 2.5, respectively, on 3-point scales). Although the use of a voucher system was novel for the therapists operating in the participating provider organizations, these organizations in collaboration with justice authorities had ongoing experience in using drug urine screens with substance abusing clients. Thus, judging from the relatively high baseline CM monitoring scores, it seems likely that drug use was already being tracked for some of these substance abusing adolescents prior to the CM workshop for adolescent substance abusing clients. If, however, one assumes that sufficient room for improvement in CM monitoring scores did exist, a possible explanation for the failure of IQA to improve CM monitoring fidelity pertains to clinical priorities. Recent research (Henggeler et al., in press) has shown that competing clinical priorities was one of the primary reasons cited by community-based mental health and substance abuse clinicians for not adopting CM with their substance abusing adolescent clients. In our study, CM was integrated into existing MST programs, where the most immediate and pressing clinical concern was to attenuate the youth and family problems that placed the youth on the verge of an outof-home placement (i.e., criminal behavior). Thus, the youths’ other delinquent behaviors such as physical aggression, theft, or running away might have been deemed as higher priorities for intervention to reduce placement risk. If this interpretation is accurate, it suggests that the introduction of a new evidence-based treatment protocol into an existing evidence-based program requires a strong linkage to the goals of greatest concern to the treatment participants and stakeholders. Two limitations of the study should be noted. The first pertains to the generalizability of the findings. To
facilitate ease of import and implementation, CM was selected as a relatively straightforward substance abuse intervention that was theoretically and clinically compatible with MST. In addition, therapists who were already providing an evidence-based treatment served as the platform for the study to attenuate barriers to CM implementation due to negative therapist and organizational attitudes toward evidence-based practices (e.g., IOM, 1998). Hence, the findings might not generalize to other evidence-based treatments or to the providers of other types of substance abuse services in agencies or programs that have not adopted evidencebased practices. A second limitation pertains to the small sample size, which attenuated statistical power. The available data, however, did not suggest trends in the nonsignificant outcomes that might have reached statistical significance if more participants had been included. Implications for Future Research, Policy, and Practice In conclusion, the findings provide some evidence for the capacity of an intensive quality assurance protocol to support and sustain the implementation of CM cognitive-behavioral interventions with marijuanaabusing adolescents. The finding that the quality assurance intervention did not increase use of CM monitoring techniques warrants additional research to test possible explanations noted previously and to spur the development of empirically grounded strategies and principles for achieving successful translation of complex combinations of evidence-based practices into sustained services for youths and families.
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