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Challenging Ourselves to Adapt: Leadership and Management Practices in the SUD Field

Blog post written by Brendan Kavanaugh LCSW,CASAC

I’m really thankful that we have advanced our clinical practice skills and training in the SUD field over the past 20 years, and I’m happy to see that our state is making a concerted effort to align clinical supervision practices with the advanced clinical practices we see in programs today. After working in 4 different states in state licensed SUD centers, the Clinical Supervision training (and requirement) is no small accomplishment for the NY SUD treatment field. Thanks to everyone who advocated for that change!

It’s now common to see clinicians with advanced degrees and state licensure entering into our practice settings with a solid foundation of trauma informed care, an affinity for DBT skills training, or cognitive behavioral methods, and a thirst for learning interventions and practice skills. We even see clinicians who are engaging frequently in post graduate training such as EMDR, EFT, and couples counseling.

In NY state the new 820 residential treatment model brought about by Medicaid redesign has led to opportunities for agencies to recruit and cultivate advanced clinical talent. While we haven’t reached the salary standards of other parts of the medical field, nor can compete with private hospitals and programs, there has been a significant improvement over the last ten years in what we can offer these talented clinicians. This has no doubt positively influenced the success of our programs at the CRW over the past 3 years. We see the impact in all of our outcomes; patient retention, satisfaction/engagement, reduction in substance use, engagement in MAT services, and improvement in vocational outcomes-just to name a few.

These workforce improvements are a far cry from the homogeneous mix of clinicians I experienced as a junior counselor 20 years ago when the field was dominated by persons working towards their CASAC certificates (yes mostly trainees indeed). During that time, we engaged in a style of directional counseling that was rooted in personal experiences and lightly based in behavioral modification. Power dynamics were present and not accounted for, and we would inadvertently assess clients acting “compliant” with our directions as successful recovery. With all the best intentions, I along with other CASAC-T’s, engaged in what we believed was the best and most compassionate way we could “give treatment”, often falling into what MI clinicians and leaders now call “the expert trap”.

Considering the history, these recent advancements in the SUD workforce have been nothing short of a monumental shift, especially with the advancement of the role of the CRPA as an integral piece of the multidisciplinary team. Have we seen this monumental shift positively impact all of our client surveys and programs outcomes in the field? It’s troubling that it should have led to dramatic improvements in program outcomes across the board. While there are programs that are enjoying the advancements in treatment model and in staffing improvements, there are many programs struggling with the changes. When I ask colleagues and clinicians in the field what is happening, they tell a familiar story.

The story I hear usually sounds like this from clinicians;

the staff really cares about the clients and cares about doing a good jobthere’s just too much staff turnover to have stability in the programeveryone (leadership, staff, clients) aren’t on the same page and it impacts the most vulnerableI got burnt out and it didn’t seem like there was any support

The story I usually hear from leadership sounds like this;

there’s too much interference from the state and Justice Center to run programs effectivelythere's not enough resources to manage effectivelywe have a shortage of experienced staff and leadersthe person-centered model has shifted things too far towards the client to maintain program integrity

Moving from clinical roles to leadership in 2010, I’ve had the benefit and challenge of managing only in the era of person-centered care. This leadership challenge outlined above was difficult to work through as a new leader, and I applaud all of the leaders who continue to dedicate themselves to this calling during these challenging times. With the maturity that trial and error has brought me, I can now simplify the challenge for leaders.

The values of leaders, indirectly or directly communicated, do not match the values of modern clinicians. Given that most middle managers are clinicians, as I was in 2010, who are making the jump to a new role, we run the risk of having a huge disconnect between leadership and the essential workforce. Leaders must value the bottom line and accountability to keep the doors open in their programs. How can you achieve accountability and respect for the bottom line in this modern era? Just as the clinical toolkit has greatly expanded, the leadership toolkit in SUD leadership can be expanded if we take some healthy risks.

My belief is that the tools we provide our leaders, supervisors, and mangers, don’t always match up to support the intangible needs of clinicians in the programs, and the clinical minded leaders who support and supervise them.

I won’t pretend to have all the answers as I’m still always learning and developing, and I still consider myself a budding executive, What I’ve seen that’s effective in connecting leadership to the clinical workforce has roots in the work we are all familiar with;

building healthy rapport with your teamsusing evidence based leadership/management methods

In the past 7 years, I have digested a fair amount of evidence based leadership and management methods from mentors and colleagues alike. Those who know me well are acutely aware that I love to share what works to improve the work culture for clinicians, as this always relates to a better client experience. After introducing a few evidence based supervision tools for the leaders of CRW in 2017 and 2018, in the beginning of 2019 I started a weekly workshop with our program directors to invest in their development. We chose the book, “Leadership Through People Skills” by the founders of Psychological Associates, Robert E. Lefton, and Victor R. Buzzotta. In short, the book is rooted in behavioral science and psychological research with the ‘Dimensional Model of Behavior’ as the core of the framework (pictured in this article). The big takeaways for our team have been;

-         developing people skills as a way of influencing change

-         using a behavior based framework for leadership self-assessment

-         using a behavior based framework for assessing those you work with

-         applying effective strategies to manage direct reports, peers, and bosses

-         using a framework for forecasting patterns of behavior to choose effective leadership strategies

-         developing skills for enhancing motivation and receptivity

-         developing effective probing skills for coaching

-         using a 5 step framework for challenging interactions

We believed that if we introduced and practiced a broader person-centered leadership framework we would match the needs of the advanced person-centered clinical practices, enhance our leadership skills, and create an attitude of openness that would positively influence our culture. In the past year, we have retained and developed our leaders and clinical staff at near 95% retention, and have consistently outperformed our expectations for client experience with 90% of our clients consistently stating they would recommend our program to a family member or friend. Our results compel us to share our methods with our partners in the community.

What I did not expect as a positive consequence is the way that our leadership team completely invested in each other’s development, bonded to one another cohesively in a way that supports safely trying out new strategies and giving constructive feedback. Our directors now work across the program lines in ways that I have never seen before- it is immensely gratifying to see this level of trust and compassion. I also was not expecting that the process would influence my feelings of personal growth, connection, and passion for the work. I am a passionate person who loves this work and who has found even more passion with this project. It just proves once again in this work, “it is always a reciprocal exchange”.

The question I encourage everyone to ask in our field, "What leadership and management models are we are using to adapt to the changing times"?

Brendan is a Board Member

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