**Abstract**

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.

**Keywords:** leadership, organizational climate, diversity, evidence-based practice, treatment effectiveness

#### **1. 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 [1–3]. 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

resources, and mitigate the risk of staff turnover [1, 5, 6]. These factors alone handicap program's ability to deliver effective services [4]. Despite these challenges, program administrators have limited formal training to increase the level of readiness of counselors to deliver evidence-based practices and measure client outcomes [2, 3, 7, 8]. SUD treatment leaders face increasing pressures from federal and state institutions to deliver evidence-based practices (EBPs) to reduce disparities between health outcomes of racial and ethnic minorities compared to Whites [9, 10]. Leadership is a key factor associated with implementation of EBPs given that organizational leaders are generally responsible for overseeing the implementation process [11]. It is necessary to understand how leadership can influence the effectiveness of care in SUD treatment.

Transformational leadership is the type of leadership that has the most empirical support in the extant literature [12]. It is generally characterized by the leader's ability to inspire others to follow a particular course of action [13]. These leaders draw from the unique talents of each staff member, provide them feedback based on staff needs, stimulate their problem solving abilities and create a sense of shared purpose [13, 14]. Although transactional leadership, which is based on reinforcing performance using rewards is also commonly used by managers [15–17], transformational leadership has demonstrated a higher impact motivating staff to improve performance, which in behavioral health generally translates into delivering treatment with fidelity [12, 14, 18].

The extant literature suggests that leadership affects implementation of EBPs both directly and indirectly by shaping the organizational context, which then influences employee behaviors [19]. This chapter focused on a deeper understanding of the leaders' relationship with followers and the role of context (organizational climate), in facilitating leadership across the organization. We focus mainly on transformational leadership and the context of service delivery of SUD treatment.

We begin laying the theoretical foundation of ways in which leadership at the director or upper management level may influence treatment staff (supervisors and counselors) to improve care. Then we highlight the differential training necessary for upper and middle level managers to improve the implementation and impact of effective practices. Upper managers need leadership training on creating buy-in using role modeling and promoting employees' professional development. In contrast, middle managers (supervisors) need leadership training on implementation approaches to prioritize, guide, promote and supervise implementation of needed practice to improve the effectiveness of care. Together, leadership at the upper and middle management levels can make a difference in improving the quality of care in SUD treatment systems.

In building a comprehensive framework of leadership in SUD treatment, we consider the role of context (i.e., organizational climate) to support the delivery of EBPs in SUD treatment. Organizational climate is considered employees' shared perception of what is rewarded, promoted, and punished in their organization. Because leaders' communication and prioritization generally show what is rewarded, promoted and punished in the workplace, it is critical to examine the relationship between leadership and climate. For instance, program directors' prioritization of new norms and expectations (e.g., quality of care) may influence counselor's adoption of those norms and endorsement of congruent practices (e.g., EBPs). Because the organizational climate (context) supports and encourages employees in implementing a new practice [20] the leader-climate-practice mechanism is critical to improve the quality of care.

Researchers have explored the leader–climate–practice mechanism in diverse fields, such as industrial safety [21], corporate customer services [22], and

*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.

#### **2. Leadership across management and direct service staff**

#### **2.1 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].

#### **2.2 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 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.

#### **2.3 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.
