Leadership Approaches to Developing an Effective Drug Treatment System

Improving the effectiveness of the substance use disorder (SUD) treatment requires leadership approaches that have an impact on the effectiveness of drug treatment. To promote this positive system change, we define leadership beyond leaders’ characteristics. We consider leadership as a developmental competency among individuals, as well as the relational role of followers and the enabling context of organizational climate which together create a system of influence. Using this developing framework, we discuss how the foundations of certain leadership styles, like transformational leadership can be enacted by program leaders to improve the human and program resources necessary to deliver culturally responsive and evidence-based treatment for some of the most vulnerable groups struggling with SUDs. Building on their transformational and implementation competencies, program leaders can promote organizational climates and program and financial approaches to deliver effective care to some of the most vulnerable populations. We provide a case study to stimulate discussion on how leadership can trickle down to staff to improve care for vulnerable clients.


Introduction
Leaders in substance use disorder (SUD) treatment organizations face significant challenges to improve the effectiveness of drug treatment system. Among the most significant challenges are responding to an increasingly diverse client population with high rates of co-occurring medical conditions and high levels of comorbidity [1]. To deliver such practices, program leaders, which represent mainly managers (directors and supervisors) need to have a workforce with reduced rates of burnout and mitigate this and other factors that lead to high turnover rates as well [1][2][3]. Additionally, program leaders need to prepare the treatment workforce to deliver evidence-based practices and sustain that delivery overtime. To do so, program leaders require leadership to implement practices that are effective and culturally responsive.
SUD treatment programs overall are challenged by limited human and program resources and poorly organized financial incentives and payment systems [4]. Leaders of these programs constantly seek to stabilize funding, improve technical Leadership Approaches to Developing an Effective Drug Treatment System DOI: http://dx.doi.org /10.5772/intechopen.91055 evidence-based health care practices [23]. Exploration of the extent to which this mechanism applies to implementing effective practices in SUD treatment is warranted.
To contextualize the leader-climate-practice mechanism in SUD, it is critical to describe the structure of this system. SUD treatment programs in the United States are generally small with an average of five to six employees, with less than 1 million in revenue and with a mix of professional and paraprofessional counselors. That is, the field has a significant number of counselors in recovery with limited formal academic education. Because these programs are small, managers have a frequent and strong relationship with treatment staff. Because the relationship among program staff is close, leadership and climate can be considered major drivers of organizational change.
The following narrative describes the theory and application of two main mechanisms whereby leadership among program directors influence middle managers (i.e. supervisors) and in turn counselors on: (1) how directorial leadership may influence middle managers and direct service staff and (2) how a supportive context, (i.e., organizational climate) may enhance the influence of leadership on direct service staff implementation of effective or EBPs.

Theoretical framework
Research suggests that director's transformational leadership is necessary to ensure the implementation of policies and practices [24] with limited studies examining the role of middle managers to contribute to implementation [25]. Leadership at different levels of management is one mechanism for implementing needed practices to improve the effectiveness of SUD treatment programs. Because SUD treatment programs generally have a director and supervisor who plays a leadership role in direct change, it is important to distinguish their contribution to improving effectiveness in treatment.
To distinguish the contribution of directors and supervisors' leadership to effectively implement EBPs, we discuss the leadership of both top and middle managers in the implementation process. For instance, how directors' transformational leadership (ability to inspire employees to follow a particular course of action) and middle managers' implementation leadership (supporting staff in implementing EBPs) may support counselors' efforts to deliver EBPs. These EBPs can include the most common and effective practices, such as contingency management treatment (CMT) and medication-assisted treatment (MAT). CMT is a psychosocial intervention based on principles of behavior modification (e.g., clients receive a gift card for a clean drug test) with significant empirical support [26]. MAT is a pharmacological intervention that relies on specific drugs (e.g. buprenorphine, vivitrol, and naloxone) to reduce cravings or block effects for alcohol and illegal drugs. Delivering these two EBPs in SUD treatment would increase its effectiveness. Unfortunately, only one third of programs offer these EBPs in the United States [27], and if offered, they are poorly or inconsistently delivered [28,29].

Top managers' transformational leadership
Treatment staff may benefit from transformational leadership from their program directors. That is, directors may communicate values, goals and vision to develop a system to improve decision making. Directors enacting transformational Effective Prevention and Treatment of Substance Use Disorders for Racial and Ethnic Minorities leadership can influence treatment staff attitudes toward, adoption and implementation of, and use of EBPs in SUD treatment [30]. In particular, directors may enhance their energy and attention in promoting staff 's professional growth and gaining their trust in director's vision. For example, on the implementation of EBPs, directors may invest in gaining buy-in from middle managers about approaches to improve quality of care, and buy-in from counselors about the benefits of delivering EBPs and achieving recovery results for clients.

Middle managers' implementation leadership
Whereas program directors may direct their energy in creating buy-in about the benefits of delivering EBPs, middle managers or supervisors can focus on communicating management commitment to implementation of EBPs [31]. Middle managers have different mechanisms to focus on this commitment through communication, training, coaching, and encouragement [32] that lead staff to changing service delivery behaviors [33].
Growing attention on middle managers' abilities to communicate, integrate, interpret, and synthesize issues are critical to support the concrete needs of counselors to implement EBPs [33]. A recently developed framework of implementation leadership is based on the foundation of middle managers' leadership approaches to be (1) proactive, (2) knowledgeable, (3) supportive and (4) perseverant to best support the implementation efforts. (1) Proactive leadership consists of problem solving behavior to accomplish implementation, while (2) knowledge leadership is well connected to the authority of knowledge about an EBP and its implementation needs; (3) Supportive leadership, authors argue is necessary to recognize, appreciate and guide employee' implementation efforts and (4) perseverant leadership challenges leaders to carry through the challenges, and address issues that may cause the implementation to falter. Together, these four categories are connected to leadership literature that is critical in influencing others, but in this case target implementation of EBPs.
When managers consistently communicate the priority of and act to support the implementation of a practice, they are more likely to influence employee action [34]. Communication with employees must come from middle managers who are the proximate manager to guide staff through the concrete, technical and cultural aspects of delivering effective treatment. Moreover, knowledgeable, supportive, and consistent approaches are expected from middle managers as staff engage in the implementation of a novel practice. Top managers or directors in turn, should focus on supporting supervisors and employees in engaging in the implementation and constantly communicate the mission and get buy-in into the overall goal of the program and commitment to quality of care.
Leadership influence across management is a social exchange across individuals with different roles, status, competencies, and responsibilities [35]. Hence, we argue that there is a cascading influence of multilevel leadership, from top managers to middle managers and from middle managers to employee attitudes and behaviors.
It is not clear how managers enacting different leadership styles operate simultaneously to influence front line workers' performance [36]. Some research has explored how specific leadership approaches and organizational context support the implementation of effective practices that improve organizational performance [37]. Although the leader-follower relationship is critical to create and promote organizational change [34], it is not clear how leaders can impact this relationship to achieve desired outcomes. We discussed the critical relationship among three main actors (top manager, middle manager and counselor) in the implementation process, but the enabling context of organizational climate may facilitate or restrict leaders' influence on organizational change.

Leadership and organizational climate influence on staff
Defined as employees' shared perception of what is expected, promoted, supported, rewarded and punished within the workplace, organizational climate could be considered a product of leadership. Leaders shape the norms and practices of the workplace, which can directly and indirectly influence implementation practices. This is particularly the case in SUD treatment programs that are generally small, hierarchical, and intimate.

Theoretical framework
Because transformational leadership behaviors are proven to create organizational change, it is warranted to consider transformational leaders to create an organizational context conducive to implementing new practices. The extant literature suggests that leaders positively or negatively contribute to the creation, development, and sustainment of an organizational climate that fosters employee attitudes and behaviors that support innovative practice use [38][39][40]. In a strong implementation climate, employees perceive new practices as a priority rather than a distraction or disruption [41,42]. Several studies have found a positive association between implementation climate and implementation effectiveness, although empirical studies of implementation climate are limited [43][44][45].

Organizational climate as a supporting factor in implementation and quality of care
The extant literature suggests that leaders may shape organizational climate through a social learning process in which staff members repeatedly interact with and observe their leader to interpret organizational priorities [39,46]. In their interaction with followers, leaders communicate the importance of various tasks through their behavior and interactions with employees. In SUD treatment, leaders develop strategic goals to communicate their organizational mission, monitor and supervise staff activities, model desired behavior, and reward staff behavior in line with the prioritized behavior or outcome [47][48][49].
Experts suggest that leaders rely on three main approaches to communicate priorities They explicitly or implicitly communicate what behavior or attitudes they value, what behavior or attitudes should be rewarded, what behavior or attitudes should be punished. By communicating their expectations and priorities in these ways, leaders develop, support, and perpetuate an organizational climate [50].

Ethnic leaders' influence on the implementation of cultural competence
The cultural background of individuals with decision making power and leadership potential has also become an important factor to consider in the study of long-term implementation of culturally responsive practices [51]. Managers' ethnic background may enhance their commitment to cultural practices that represent their values and experiences serving racial/ethnic minorities. This familiarity with cultural background and life experience may be a powerful enabler of implementation of culturally responsive and evidence-based practices. There is a need to address implementation in this context, as it can help SUD treatment programs located in minority communities to consistently respond to the cultural and language service needs of racial and ethnic minority patients [52].
We propose that it is critical to explore how leadership cascades from top management to direct service, how climate can be an enabling factor to deliver quality of care, and finally how the ethnic background of transformational leaders may help the implementation process that included service practices that are culturally tailored, and directed toward cultural minorities.
Although there may be other barriers and facilitators of implementation of culturally responsive and evidence-based practices, as well as an abundant literature on leadership approaches to promote organizational change, this chapter describes active components of leadership and the organizational context that may drive the implementation of EBPs in SUD treatment organizations. By enacting leadership styles at different levels, and promoting a supporting climate for implementation, SUD treatment leaders may work on specific transformational behaviors among directors, implementation leadership at the supervisor level, and organizational climate to support the implementation process.
Although the characteristics of leaders are associated with organizational outcomes, critical characteristics like ethnic background is associated with increased commitment to deliver culturally responsive SUD treatment. Ethnic minority leaders may enhance the delivery of quality of care in SUD treatment to minority clients.

Implications for management to support treatment effectiveness
The proposed conceptual model highlights how leadership, conceptualized as influence on employees to deliver quality of care relies on managers at different levels, and can be supported by the climate of the organization. Because individuals within SUD treatment programs have different roles, responsibilities and skills, it is important to understand how each of these individuals may best prepare to implement culturally responsive and evidence-based care that enhance treatment effectiveness.
Upper managers, or program directors should consider building on their leadership abilities to communicate a vision for the treatment programs consistent with treatment effectiveness. Directors should also build competencies to appraise individual strengths, communicate them to staff, and learn how to link these strengths with program goals. To accomplish this task, directors should allow themselves to spend significant time and resources positively relating to staff, including middle managers or supervisors. Obtaining buy-in from supervisors should be one of the director's goal. By developing credibility and trust among supervisors, directors would be able to reach direct service staff, or counselors. In short, directors should invest in transformational leadership qualities that build on a genuine person with a clear view of what is to be accomplished and with a sincere approach to supporting the professional growth of staff.
Middle managers or [clinical] supervisors should consider building on their leadership abilities to help staff effectively implement practices. Building on capacities to be proactive and respond to staff questions and comments about the implementation process or the practice to be implemented is critical. Supervisors should also invest in developing the knowledge of both the implementation process as well as the EBPs considered for implementation and ways to evaluate their outcomes. Supervisors should also demonstrate supportive leadership to recognize, appreciate, and guide staff 's implementation efforts. Finally, the supervisor's need to role model perseverant leadership to carry through the challenges and address all the many shortcomings during the implementation process. These four approaches provide a capacity-building plan for supervisors to enhance the transformational leadership efforts from their program directors, and contribute concrete capacities to influencing staff to deliver quality of care.
Both, upper and middle managers, using their own leadership approach can start shaping the organizational climate of the treatment organization. But for the climate to be a driver of quality of care, both manager types need to be consistent in communicating their priorities to treatment staff and reducing any contingencies that may keep staff from achieving program goals. Supplementing an organizational climate that supports the delivery of culturally responsive and evidencebased care can become an active driver of quality of care.

Case example
John Clark, a Caucasian male in his upper 60s was generally regarded as a friendly and hard-working program director. He managed one of over 400 substance use disorder treatment programs located in one of the largest cities in the West Coast. Like most others, his program had a supervisor overseeing 5 counselors, 3 coordinators and 2 office staff. Mr. Clark was often proud that he promoted a great sense of collegiality among his staff and that his workplace was always jovial and productive. During state and county meetings, he also reaffirmed his commitment to cultural competence in response to the increasing client diversity in his program. Almost half of his clients were women, and 70 percent self-report a non-White racial background.
During program meetings, Mr. Clark emphasized the importance of delivering evidence-based practices tailored to their diverse population. He often delivered expectations with a great sense of humor, which made program meetings entertaining. But staff were growing frustrated by the lack of meaningful support to implement the proposed EBPs. Staff were also constantly confused how to adapt EBPs to meet the service needs of women, Latinos and African Americans, their main demographics.
Among his peers at other programs, Mr. Clark was a leader in the field, while in his program, there was an increasing frustration by what many saw as "empty rhetoric." Meanwhile, Ms. Jenkins, a 55-year-old Caucasian clinical supervisor spent most of her time dealing with billing and human resources issues, not able to provide meaningful support to deliver quality of care. Treatment staff were constantly pulled in different directions to comply with billing issues, while their professional development and self-efficacy needs were not addressed.
Juan Lopez, a 60-year-old Latino counselor was the most vocal staff complaining about the lack of counselor diversity and limited evaluation of program effectiveness. For years, he had requested additional Spanish speaking counselors with training in mental health issues to respond to the increasing numbers of Latino clients suffering from mental health and substance use disorders. Juan and some of his peer also needed more training to respond to the higher severity of mental health issues they were encountering with their clients. The treatment staff requested more guidance and evaluation of their current practices. They grew frustrated with an increasing number of clients who passed through their program two to three times a year with limited signs of progress.
These program and service delivery concerns started to reach funders and Mr. Clark's leadership on delivering effective and culturally responsive care was being challenged among his peers. The program was losing funding. Some funders suspended funding or added restrictions based on showing evidence of program performance. Two of the five treatment staff and one of the office staff resigned and move to another nearby program.

Conclusion
Leaders in SUD treatment face significant challenges to improve the effectiveness of drug treatment. As this treatment system must withstand funding uncertainty, limited technical resources and workforce development needs [1,5,6], program managers require unique leadership approaches. Training managers to develop their leadership capacity to help their staff implement EBPs with fidelity has become a unique feature to improve effectiveness needs in this system [53].
However, like other human service organizations, program leaders in SUD treatment may need to develop a comprehensive organizational development plan. This plan may include a professional pipeline to prepare counselors and early managers from racial and ethnic minority backgrounds to become competent middle and upper managers [54]. This approach would response to the increasing cultural diversity in the client population, as well as the diversity of their co-occurring medical conditions. The framework proposed in this chapter highlights some of the most significant problems that the SUD treatment system faces-funding, technology and workforce. We discussed a leadership approach that assumes a trickledown effect where leading managers are more likely to develop effective counselors, and where these counselors are better prepared to respond to the recovery service needs of a diverse client population.
To enhance and sustain effectiveness in SUD treatment, a leadership capacity plan may also include a succession planning and alignment. Leaders in the SUD treatment system may reduce uncertainty in operations and funding and increase equity and inclusion with a comprehensive vision. The extant literature on leadership offers a wealth of examples on how leaders' vision activates followers and lead to organizational effectiveness [12][13][14]. To support the delivery of effective care, competent leaders may promote an organizational climate of trust and align resources to sustain service delivery [54]. This organizational climate can enable learning among staff to gradually improve the quality of care. Moreover, having an effective and inclusive succession plan and a climate of trust and support may become the driver of quality of care. In short, it may be that through the development of transformational leadership that program managers may be able to shape the human and program resources to reliably help clients achieve recovery.
To help SUD treatment systems to deliver effective care, a research agenda needs to consider modifiable organizational factors that make evidence-based treatment effective. One of these drivers is leadership, considered "influence" in the system. Organizational interventions need to include leaders, followers and context to have a "system of influence" that impact effectiveness. Policy makers, healthcare administrators, program managers and counselors may benefit from developing this leadership approach to improve recovery.