##### Substance Abuse/Homeless Rehabilitation Emphasis Area Training

The Substance Abuse/Homeless Rehabilitation emphasis area includes
training opportunities in both outpatient and residential settings (see
Settings section below for further details). During the fellowship year,
the expected competencies to be acquired will closely follow the VA/DoD
Clinical Practice Guidelines for Substance Abuse Treatment (developed
with the Substance Abuse and Mental Health Services Administration and
the Center for Substance Abuse Treatment). These specific competencies
include addiction-focused psychosocial therapy, brief motivational
enhancement strategies, short-term individual psychotherapy, group
therapy, milieu therapy, consultation skills, liaison skills, assessment
of specific patient populations (e.g., dually diagnosed patients, SMI
patients, homeless patients), and behavioral modification techniques.
These competencies form the basis of the fellowship program emphasis
area goals and objectives.

The Substance Abuse/Homeless Rehabilitation Fellow will spend 60% time
in clinical service, 20% time in research, and 20% time attending
didactics and providing teaching and supervision. The Fellow will select
a primary Psychology Preceptor for the year. The Fellow and his/her
preceptor will determine which training sites, additional rotations, and
research tasks the Fellow will pursue, based on an assessment of the
competencies the Fellow has already acquired and the competencies in
which he/she has not yet had experience. It is expected that some of the
time (in clinical service, research, or provision of supervision) also
will provide greater depth of experience in a competency area (or areas)
in which the Fellow has particular interest.

The Fellow will participate in interprofessional team meetings, attend
and deliver in-service presentations, and actively engage in team
treatment planning. At least 20% of the Fellow\'s time will be dedicated
to research and/or program evaluation. Current projects include but are
not limited to the following: Implementation of brief motivational
techniques by paraprofessionals, telemental health continuing care for
substance abuse treatment, biofeedback and emotional management
techniques in relapse prevention, as well as program evaluation and
quality improvement projects at each training site.

In this emphasis area, outpatient training will occur in the Addiction
Consultation & Treatment (ACT) team, which provides assessment and
diagnosis of patients with substance use disorders (SUD), screening and
triage to varying levels of care (e.g., brief therapy, day treatment,
residential treatment), addiction-focused pharmacotherapy, and
outpatient individual and group treatment for patients with SUD. The
residential training will occur in one of three residential
rehabilitation programs: Foundation of Recovery Program (28-day
Substance Abuse Treatment Program with 18 beds), First Step Program
(90-day Substance Abuse Treatment Program with 30 beds), and the
Homeless Veterans Rehabilitation Program (a 180-day National Center of
Excellence in the treatment of the homeless with 70 beds, described in
more detail below). The residential programs all provide 1) Milieu
treatment including community meetings; 2) Small group therapy; 3) Case
management; 4) Psychoeducational skills-building classes (e.g., relapse
prevention, 12-Step facilitation, communication); 5) Recreational and
leisure activities; and 6) Weekly aftercare outpatient group. The Fellow
will also have the opportunity to work with researchers in the HSR&D
Center for Health Care Evaluation (described in more detail below) on
new or ongoing research relevant to the emphasis area and the fellow's
clinical and research interests.

The actual **training plan** for the Substance Abuse/Homeless
Rehabilitation Fellow will be developed with the assistance of a Primary
Preceptor who will help plan the fellow\'s over-all program, ensure
sufficient depth and breath of experience and, plan which of the
Substance Abuse/Homeless Rehabilitation faculty will serve as
supervisors during the fellowship year. The Training plan will specify
in which of the many possible training venues the Fellow will have
comprehensive rotations with options of mini-rotations. The aim is to
ensure attainment of general clinical competencies as well as to provide
experience in each of the emphasis area-specific competencies.

**Homeless Veterans Rehabilitation Program, Domiciliary Service**
**(347-B, MPD)**

**Supervisory/Psychology Staff:**

**Keith Harris, Ph.D., Service Chief**

**Joel Rosenthal, Ph.D., Coordinator of Clinical Services**

**Larry Malcus, Ph.D.**

**Susan Anderson, Ph.D.**

**1. Patient population:**

-   Male and female veterans who have been homeless for periods ranging
    from less than one month to over 10 years.

-   Nearly 100% have history of substance dependence, 90% diagnosed with
    personality disorders, 50% diagnosed with at least one other
    psychiatric diagnosis (e.g., 30% mood disorder, 15% anxiety, 5%
    psychotic disorder).

**2. Psychology's role:**

-   Direct clinical service: Participation in all milieu activities,
    including facilitation of community meetings, group therapy,
    psychoeducational classes; 1:1 assessment and therapeutic support;
    treatment planning and consultation with residents

-   Administration: Psychologists fill the positions of Chief of
    Domiciliary Service and Coordinator of Clinical Services.

-   Research: A psychologist has been the principal investigator on
    every study conducted at HVRP

**3. Other professionals and trainees:**

-   3 Social Workers (Assistant Chief of Domiciliary and 2 staff Social
    Workers), 2 Registered Nurses, Addiction Specialist, Recreation
    Therapist, Consulting Psychiatrist, 10 Paraprofessional Health or
    Rehabilitation Technicians (functioning as peers with the
    professional staff), Predoctoral psychology, social work, and
    chaplain interns, nursing students

**4. Clinical services delivered:**

-   Empirically supported cognitive-behavioral techniques in an
    integrated therapeutic community approach

-   Services are delivered in various settings, including milieu
    meetings, group therapy, skills training classes (e.g., relapse
    prevention, cognitive restructuring, communication), and individual
    assessments and interventions

**5. Fellow's role:**

-   Programs may be designed to include participation in many program
    components, with a recommended balance of 50% clinical activities,
    and 50% research/administrative activities:

    -   Clinical Activities

        -   Residential treatment: Facilitating groups and skills
            training classes, participating in milieu meetings,
            conducting individual assessments and interventions

        -   Outreach and screening: Informing homeless veterans and
            service professionals about available services; assessing
            applicants using a biopsychosocial model

        -   Aftercare: Facilitating support groups, assisting in
            developing support systems and managing life problems,
            vocational counseling

    -   Research Activities

        -   Participating in ongoing research projects and/or new
            studies concerning the treatment of homelessness,
            personality disorders, and substance abuse, with attention
            to the integration of research and outcome data in the
            clinical treatment of the homeless

    -   Administrative Activities

        -   Completing administrative/leadership tasks as assigned by
            the Service Chief or the Clinical Coordinator (e.g.,
            analyses of the VERA reimbursement model, staff training in
            empirically supported treatments, development of regional
            and national policy regarding residential rehabilitation
            treatment).

**6. Amount/type of supervision:**

-   Weekly supervision provided by primary supervisor, with additional
    group supervision as part of daily staff meetings.

-   Orientations include cognitive-behavioral and interpersonal, with
    consultation available from any of the four psychologists on staff

**7. Didactics:**

-   Participation in Domiciliary Service education and training
    presentations.

    -   Past presentations include Teaching of Communication Skills,
        Utilization of Cognitive Behavioral Techniques, and Motivational
        Interviewing.

**8. Pace:**

-   Timely documentation is expected following significant clinical
    contact with residents in the program. Fellows are expected to
    complete clinical assessments at the time of admission, discharge,
    and/or integrated clinical summaries prior to treatment reviews.

The treatment program at HVRP is characterized by the concept of
personal responsibility (i.e., "I create what happens to me") and faith
in the individual's capacity for learning new behavior. The program
ethic is expressed as "The Five P's": Personal Responsibility, Problem
Solving, Practice, People (Affiliation), and Play. A unique aspect of
the treatment program is its emphasis on play, which is viewed as a
competing reinforcer to drugs and alcohol and as a means to lifestyle
change. Residents participate in activities such as camping, fishing,
and ski trips; sports teams (e.g., city-league softball and basketball);
holiday, birthday, and graduation parties; and program dances. Within
the treatment program, individual interventions reinforce and supplement
group work. Residents move through three phases of treatment during the
typical 6-month inpatient stay. To advance from phase to phase,
residents must demonstrate increased proficiency in skills and ongoing
practice of those skills in an expanding range of settings. In addition,
residents are expected to demonstrate leadership, a willingness to
consider feedback from staff and peers, and the application of the
personal responsibility concept to their lives. Graduation from the
program occurs with an additional 13 weeks of aftercare treatment and
allows the veteran to become a part of the active Alumni Association.

The overall goal of the postdoctoral fellowship at HVRP is to provide
fellows with a variety of experiences in an applied setting, using a
scientist-practitioner framework, and stressing the importance of
building an effective, comfortable, professional identity. Fellows are
encouraged to participate in the full array of treatment approaches,
ranging from the traditional (e.g., group therapy) to the nontraditional
(e.g., participation on sports teams or camping trips). In addition to
acquiring and refining clinical skills, objectives for fellows include
the following: developing competency as a member of an interdisciplinary
team; acquiring a sense of professional responsibility, accountability,
and ethics; becoming aware of how one's experience and interpersonal
style influence various domains of professional functioning; and
developing abilities necessary for continuing professional development.

HVRP's diverse interdisciplinary staffing pattern is unusual for a
medical center service insofar as psychologists occupy key
administrative positions which allow fellows more direct
access\--through observation, participation, and supervision\--to the
processes of organizational behavior management, program development,
and policy-making. This allows fellows to receive administrative and
clinical leadership training in addition to the clinical training
described above. This training will be provided and supervised by the
Chief, Domiciliary Service as well as the Domiciliary Coordinator of
Clinical Services. Areas of training will include the role of the
administrator in the integration of services within the hospital and
local community and the negotiation of national and regional policy as
well as the internal administrative and program development and
maintenance functions. The fellow will have an opportunity to be
involved in the leadership and decision-making process of a system which
is characterized by an active strategic planning and program change
process, a state-of-the-art clinically driven computerized medical
records system, and a dynamic staff development and negotiation
structure.

**Addiction Consultation & Treatment, Addiction Treatment Services**
(321, MPD)

Supervisory/Psychology Staff:

Paula Wilbourne, Ph.D., Director, Addiction Treatment Services

Rachael Guerra, Ph.D., Clinical Coordinator, Addiction Consultation &
Treatment

Simon Kim, Ph.D., Staff Psychologist, Addiction Consultation & Treatment

1\. Patient population:

-   Male and female veterans seeking assessment and treatment for
    substance use disorders

-   Over 50% have other co-morbid Axis I diagnosis, about 25% have Axis
    II diagnosis or traits; over 50% are homeless

2\. Psychology's role:

-   Direct clinical service: Involved in assessment of patient and
    treatment planning, provide group and individual therapy, case
    manage patients waiting for residential treatment

-   Administration: Psychologists fill the positions of Director of
    Addiction Treatment Services (ATS) and Clinical Coordinator of
    Addiction Consultation and Treatment (ACT). They provide supervision
    for 2-3 psychology practicum students. They provide speciality
    training in substance use disorder treatment. They engage in program
    development and evaluation. They lead team and case review meetings.
    They also monitor hospitals' progress on VA Mental Health
    Performance Measures.

-   Research: Researchers from the Center for Health Care Evaluation
    recruit from ACT's patient population for their studies.

3\. Other professionals and trainees:

-   2 Social Workers (1 Senior Social Worker and Admission coordinator),
    3 Registered Nurses, 2 paraprofessional Addiction Therapists, 1
    Psychiatrist (ACT & ATS Medical Director), 1 medical clerk, social
    work interns, psychology practicum students, and nursing students

4\. Clinical services delivered:

-   Group and individual outpatient treatment for veterans who have
    substance use disorders (including treatment for dual diagnosis and
    chronic pain)

-   Offering process oriented group therapy and evidence-based
    interventions including Relapse Prevention, 12-step Facilitation,
    Motivational Interviewing, Mindfulness-Based Relapse Prevention, and
    Seeking Safety

-   Consultation and referral to ATS residential treatment programs
    including crisis management, referral to community resources, and
    assessment of acute intoxication and/or withdrawal potential,
    readiness to change, and relapse/continued use or continued problem
    potential

-   Case management for veterans preparing for residential treatment

-   Aftercare for veterans who have completed a residential or
    outpatient addiction treatment program

5\. Fellow's role:

Programs may be designed to include participation in many program
components including both clinical and research/administrative
activities:

-   Clinical Activities

    -   Outpatient treatment: Facilitating groups, conducting individual
        screening/assessments, interventions and case management,
        consultation to other services in the hospital (inpatient
        psychiatry, medical units, OIF/OEF Programs, etc.)

    -   Aftercare: Facilitating support/process groups

-   Research/ Program Evaluation Activities

    -   Participate in tracking patient demographics, characteristics
        and outcomes

    -   Tracking process variables such as admission wait time, possible
        barriers to accessing treatment, aftercare follow-up, etc.

-   Administrative Activities

    -   Completing administrative/leadership tasks as assigned by
        Postdoctoral Supervisor and program leadership (including but
        not limited to staff training, leading team meetings, monitoring
        Performance Measures, liaison with other hospital programs,
        program development)

6\. Amount/type of supervision:

-   Weekly supervision provided by primary supervisor, weekly
    supervision with other ATS psychologists and psychology trainees,
    with additional group supervision as part of staff/case review
    meetings

-   Orientations include cognitive-behavioral and interpersonal with
    special emphasis on multicultural issues. Consultation available
    from any of the psychologists within ATS as well as psychologists in
    Mental Health Clinic.

7\. Didactics:

-   Participation in ACT education and training presentations.

    -   Past presentations include: Utilization of Cognitive Behavioral
        Techniques, Psychosocial Rehabilitation, Motivational
        Interviewing, patient risk assessment, Substance Use Disorders
        among the Elderly, dual diagnosis, and evolution of mental
        health and addiction treatment within the VA.

8\. Pace:

-   Timely documentation is expected following significant clinical
    contact with patients. Assessments must be completed in a timely
    manner so that case can be presented to the ACT team and referral
    sources can quickly respond to ACT recommendations. Patients that
    are waiting for admission to a residential treatment programs have
    once a week case management contacts.

ACT\'s mission is the following:

> \"Empowering and instilling hope for veterans with substance use
> disorders by providing client-focused, comprehensive assessment and a
> range of treatment modalities in collaboration with an
> interdisciplinary team and the community at large.\"

ACT strives to help veterans with substance use disorders, as well as
other mental health diagnoses, to access treatment that is appropriate
for the severity of their problems and their readiness for change. We
respect the multiple identities and varying circumstances of our
patients. ACT providers try to gain an understanding how the many
factors at play in the patient\'s life effect and are affected by their
substance use and work collaboratively with the patient on their
identified problems and goals. We also respect that people recover from
addiction in many ways, and offer many different types of treatment
including outpatient group and individual therapy, referral to
residential treatment, medication management, self-help, bibliotherapy
and web-based guided self-assessment.

The goal of the postdoctoral fellowship at ACT is to gain an awareness
of the many ways substance use effects the lives of our veterans
(psychologically, physically, medically and spiritually), and to gain an
understanding the process that veterans go through to change their
substance use and other maladaptive behaviors. Using the
scientist-practitioner framework, fellows will develop their own
"working model" about the etiology and treatment of substance use
disorders, and become familiar with the many and varied methods that are
used to help individuals recovery from addiction. Fellows become an
important part of the interdisciplinary team, and through their clinical
and/or administrative duties learn what it means to be a psychologist
within a VA Healthcare System. Postdoctoral training in ACT focuses on
acquiring knowledge across the many different aspects of the disease of
addiction and being able to apply that knowledge to recommend and apply
appropriate treatments. Supervision also focuses on patient diversity,
professional ethics, career development and awareness of trainees'
worldview and interpersonal style and their influence on one's clinical
work and professional development. An additional training focus that ACT
offers is administration and leadership in provision of outpatient
mental health services. Like training at the Homeless Veterans
Rehabilitation Program (HVRP), the fellow can be mentored in the areas
of organization management, program development, creation of policies
and procedures, quality improvement and/or program evaluation. Unlike
HVRP, the fellow learns these skills in the context of outpatient mental
health services and the circumstances and challenges that differentiate
outpatient treatment from the more intensive level of residential care.

**Health Services Research & Development**

**Center for Health Care Evaluation (CHCE, Building 205, MPD)**

**Supervisor(s):** **Elizabeth Gifford, Ph.D.**

**Keith Humphreys, Ph.D.**

**John McKellar, Ph.D.**

**Craig Rosen, Ph.D.**

**Ken Weingardt, Ph.D.**

**1. Patient population**: Psychiatric and substance abuse patients
participating in research studies.

**2. Psychology's role**: CHCE researchers, many of whom are
psychologists, play a critical role in development, dissemination,
delivery, and evaluation of clinical services. At CHCE, psychologists
conceive and answer important questions about outcomes, quality, and
costs of publicly funded mental health services.

**3. Other professionals and trainees**: The CHCE community includes a
variety of experts in health services, including health economics,
epidemiology, public health, medical sociology, and biostatistics.

**4. Nature of clinical services delivered**: No direct clinical
services are provided.

**5. Fellow's role**: In consultation with a research mentor, fellows
develop and implement a research project related to one of the Center's
several ongoing studies. Over the course of the rotation, fellows are
expected to develop a report of their project that is suitable for
presentation at a scientific conference and/or publication in a
peer-reviewed journal.

**6. Amount/type of supervision**: One or two research mentors are
assigned to each fellow. Supervision will be as needed, typically
involving several face-to-face meetings per week.

**7. Didactics:** The Center sponsors a weekly forum on a variety of
relevant health sciences topics; attendance is required. The research
mentor and fellow may choose to incorporate additional seminars, e.g.,
Grand Rounds, presentations at Stanford, study groups, etc. The fellow
and mentor will determine readings relevant to the chosen research
project and areas of interest.

**8. Pace**: The goal of completing a research project from conception
to write up within six months requires skillful time management.
Rotation supervisors help the fellow develop a rotation plan. Fellows at
CHCE benefit from a coherent rotation focus with minimal additional
requirements.

The HSR&D rotation offers fellows ongoing professional development as
clinical researchers within the context of a national center of research
excellence. The Center for Health Care Evaluation
([CHCE](http://www.chce.research.va.gov/)) is one of the VA Health
Services Research and Development Service's (HSR&D) national network of
research centers. CHCE is also affiliated with the Stanford University
School of Medicine. CHCE\'s mission is to conduct and disseminate health
services research that results in more effective and cost-effective care
for veterans and for the nation\'s population as a whole. We work to
develop an integrated body of knowledge about health care and to help
the VA and the broader health care community plan and adapt to changes
associated with health care reform. One main focus of the Center is on
individuals with psychiatric and substance use disorders. Secondary foci
of direct interest to clinical and counseling psychology fellows include
the organization and delivery of mental health treatment services, the
costs of care, and clinical practice guidelines.

Fellows at CHCE become involved in activities designed to improve their
ability to conduct and interpret health services research. The
organizational philosophy at the Center is strongly emphasized in its
fellowship rotation: We believe that a collaborative, clear, and
supportive work environment contributes to professional development and
training outcomes. Fellows are expected to attend presentations that are
relevant to the field, read research articles related to their research
topic, and generally participate in the intellectual life of the Center.
Fellows may receive training in a range of research skills, including
quantitative and/or qualitative methods, assessment, statistics, data
management, and statistical programs such as SPSS and SAS. Fellows may
also receive mentoring on professional development issues, e.g.,
integrating clinical practice experiences and knowledge into
conceptualization of health services research questions, clarifying
their own research interests and goals, applying for research-related
jobs, scientific writing, grant proposal writing, project
administration, publishing, presenting at professional meetings. This
rotation may be particularly useful for fellows who are planning
academic/research careers or are preparing for administrative/clinical
roles in which understanding and conducting health services research
(e.g., program evaluation) is a major professional activity. Goals for
the HSR&D fellowship rotation include the following:

> ***Fellows will participate in an effective research- oriented work
> environment.*** The Center's organizational culture is both
> interpersonally supportive and intellectually stimulating. In the
> fellowship rotation, this culture includes encouraging and modeling
> effective professional communication, establishing collegial
> mentorship relationships between supervisors and fellows, encouraging
> collaboration rather than competition, providing clear expectations
> and role descriptions, helping fellows acquire skills, and supporting
> the fellow in defining and achieving their own training goals.
>
> ***Fellows will be able to ask effective health services research
> questions*** by integrating clinical practice experiences into
> conceptualization of health services research questions, analyzing and
> understanding relevant research literatures, and connecting health
> services research questions with important VA and non-VA health care
> policy and services issues.
>
> ***Fellows will develop as professional health science researchers***
> by clarifying their own health science research interests, developing
> collaborative communication skills within interdisciplinary clinical
> research settings, seeking consultation when appropriate, defining and
> achieving their own professional goals, and functioning as a
> productive member of an intellectual community. Fellows should be able
> to attend to issues of race and culture in research conceptualization
> and implementation, including understanding the influence of one's own
> racial/ethnic background and those of research participants.
>
> ***Fellows will acquire relevant research competencies,*** including
> selecting and employing appropriate quantitative and/or qualitative
> data analytic methods, selecting or designing valid and reliable
> instruments, completing presentations suitable for presentation at a
> professional conference/submission to a professional journal, and/or
> understanding the basic mechanics of grant proposal writing and
> project management.

**Recent and ongoing studies at the CHCE**:

12-Step/Cognitive-Behavioral Comparison and Follow-up

Clinical Practice Guidelines Implementation

Community Residential Facilities Evaluation

Components of Effective Treatments for Dually Diagnosed Patients

Continuity in Substance Abuse Care

Cost of VA Research Administration

Depression Treatment Outcome

Effectiveness of Neonatal Intensive Care

Exclusion Criteria in Alcoholism Treatment Research

Facilitating Substance Abuse Patients' Self Help Participation

Hospital Organization/Demand for Services

Improvement of Substance Use Disorder Care

Meta-Analysis of Alcoholism Treatment Outcome

Outcomes of Opioid Dependence Treatment

Parental Depression and Alcohol Abuse

Patient Outings in Hospital v. Community Based SUD Treatment Programs

Patient-Rx Matching for Dual Diagnosis Patients

Problem Drinking Among Older Adults

PTSD and Health Among VA Primary Care Patients

Rehabilitation Costs

Self-Help & Mutual Support Groups

Substance Abuse and Psychiatric Programs\' Structure and Treatment
Process

Substance Abuse Outcomes/Addiction Severity Index Data

Substance Abuse Patients\' Utilization and Substance Abuse Program
Budgeting

System for Monitoring Substance Abuse Outcomes and Care

Telephone Case Monitoring for Veterans with PTSD

Telephone Intervention for Smoking Cessation

Treated/Untreated Problem Drinkers

Utilization of Care and Clinical Outcomes of PTSD Patients

Further information on the Center's activities is available by request,
and on the website at
[http://www.chce.research.med.va.gov](http://www.chce.research.med.va.gov/).