**3.1 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 [38–40]. 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 [43–45].

### **3.2 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 [47–49].

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].

## **4. 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.

#### **5. 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,

#### *Leadership Approaches to Developing an Effective Drug Treatment System DOI: http://dx.doi.org/10.5772/intechopen.91055*

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.

#### **6. 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.


#### **7. 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 [12–14].

*Leadership Approaches to Developing an Effective Drug Treatment System DOI: http://dx.doi.org/10.5772/intechopen.91055*

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.

#### **Acknowledgements**

We would like to acknowledge the support and contributions of the Integrated Substance Abuse Treatment to Eliminate Disparities (www.isated.com) research team. In particular, we recognize the support of Veronica Serret, Angelique Montgomery and Yinfei Kong to develop the material presented in this chapter. We would also like to acknowledge the support and feedback provided by the Los Angeles County Department of Public Health leaders and in particular, Dr. Tina Kim, the director of research for the Substance Abuse Prevention and Control.

### **Conflict of interest**

The authors declare no conflict of interest.

#### **Thanks**

We thank the large network of treatment providers that have provided feedback to different versions of the material presented in this chapter through their participation in the numerous research projects conducted in Los Angeles County, California. Without their support and feedback, the authors could not have developed the material presented in this chapter.

#### **Abbreviations**


### **Author details**

Erick G. Guerrero1 \* and Tenie Khachikian<sup>2</sup>

1 I-Lead Institute, Research to End Healthcare Disparities Corp, Santa Monica, CA, United States

2 University of Chicago, Chicago, IL, United States

\*Address all correspondence to: erickguerrero454@gmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Leadership Approaches to Developing an Effective Drug Treatment System DOI: http://dx.doi.org/10.5772/intechopen.91055*

## **References**

[1] Substance Abuse and Mental Health Services Administration. Substance abuse treatment facilities provide programs to fit clients; 2007. Available from: http://www.samhsa.gov/ newsroom/advisories/0706140319.aspx

[2] Center for Substance Abuse Treatment (CSAT). Clinical supervision and professional development of the substance abuse counselor. Treatment Improvement Protocol (TIP) Series 52, DHHS Publication No. (SMA) 09-4377. Rockville, MD: Substance Abuse and Mental Health Administration; 2009a

[3] Center for Substance Abuse Treatment (CSAT). Implementing change in substance abuse treatment programs. Treatment Improvement Protocol (TIP) Series 31, DHHS Publication No. (SMA) 09-4377. Rockville, MD: Substance Abuse and Mental Health Administration; 2009b

[4] McLellan AT, Carise D, Kleber HD. Can the national addiction treatment infrastructure support the public's demand for quality care? Journal of Substance Abuse Treatment. 2003;**25**(2):117-121. DOI: 10.1016/ S0740-5472(03)00156-9

[5] D'Aunno T. The role of organization and management in substance abuse treatment: Review and roadmap. Journal of Substance Abuse Treatment. 2006;**31**:221-233

[6] Roman PM, Ducharme LJ, Knudsen HK. Patterns of organization and management in private and public substance abuse treatment programs. Journal of Substance Abuse Treatment. 2006;**31**(3):235-243. DOI: 10.1016/j. jsat.2006.06.017

[7] Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation research: A synthesis of the literature. FMHI Publication

No. 231. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, National Implementation Research Network; 2005

[8] Rawson R, McCleland T. Healthcare reform and treatment: Changes in organization, financing, and standards of care. Posted presented at the meeting of County Alcohol and Drug Program Administrators' Association of California. Sacramento, California; 2010

[9] Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-First Century. Washington, DC: National Academies Press; 2001

[10] Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2013

[11] Battilana J, Gilmartin M, Sengul M, Pache AC, Alexander JA. Leadership competencies for implementing planned organizational change. The Leadership Quarterly. 2010;**21**:422-438

[12] Judge TA, Piccolo RF. Transformational and transactional leadership: A meta-analytic test of their relative validity. The Journal of Applied Psychology. 2004;**89**:755-768

[13] Bass BM, Avolio BJ. Improving Organizational Effectiveness through Transformational Leadership. Thousand Oaks: Sage; 1994

[14] Bass BM, Avolio BJ, Jung DI, Berson Y. Predicting unit performance by assessing transformational and transactional leadership. The Journal of Applied Psychology. 2003;**88**:207-218

[15] Aarons GA, Ehrhart MG, Farahnak LR, Sklar M. Aligning leadership across systems and organizations to develop a strategic climate for evidence-based. Annual Review of Public Health. 2014;**35**:255-274

[16] Aarons GA, Ehrhart MG, Moullin JC, Torres EM, Green AE. Testing the leadership and organizational change for implementation (LOCI) intervention in substance abuse treatment: A cluster randomized trial study protocol. Implementation Science. 2016;**12**(1):29

[17] Aarons GA, Ehrhart MG, Farahnak LR. The implementation leadership scale (ILS): Development of a brief measure of unit level implementation leadership. Implementation Science. 2014;**9**:45

[18] Aarons GA. Transformational and transactional leadership: Association with attitudes toward evidencebased practice. Psychiatric Services. 2006;**57**:1162-1169. DOI: 10.1176/appi. ps.57.8.1162

[19] Dinh JE, Lord RG, Gardner WL, Meuser JD, Liden RC, Hu J. Leadership theory and research in the new millennium: Current theoretical trends and changing perspectives. The Leadership Quarterly. 2014;**25**:36-62

[20] Zohar D. The effects of leadership dimensions, safety climate, and assigned priorities on minor injuries in work groups. Journal of Organizational Behavior. 2002;**23**:75-92

[21] Zohar D. Safety climate: Conceptualization, measurement, and improvement. In: Schneider B, Barbera KM, editors. The Oxford Handbook of Organizational Climate and Culture. New York: Oxford University Press; 2014. pp. 317-334

[22] Schneider B, Ehrhart MG, Macey WH. Organizational climate and culture. Annual Review of Psychology. 2013;**64**:361-388

[23] Aarons GA, Ehrhart MG, Farahnak LR, Sklar M. Aligning leadership across systems and organizations to develop strategic climate for evidence-based practice implementation. Annual Review of Public Health. 2014;**35**:255-274

[24] Guerrero GE, Kim A. Organizational structure, leadership and readiness for change and the implementation of organizational cultural competence in addiction health services. Evaluation and Program Planning. 2013;**40**:74-81

[25] Aarons GA, Ehrhart MG, Farahnak LR, Hurlburt MS. Leadership and organizational change for implementation (LOCI): A randomized mixed method pilot study of a leadership and organization development intervention for evidencebased practice implementation. Implementation Science. 2015;**10**:11

[26] Prendergast M, Podus D, Finney J, Greenwell L, Roll J. Contingency management for treatment of substance use disorders: A meta-analysis. Addiction. 2006;**101**:1546-1560. DOI: 10.1111/j.1360-0443.2006.01581.x

[27] Knudsen HK, Abraham AJ, Oser CB. Barriers to the implementation of medication-assisted treatment for substance use disorders: The importance of funding policies and medical infrastructure. Evaluation and Program Planning. 2011;**34**:375-381. DOI: 10.1016/j.evalprogplan.2011.02.004

[28] Manuel JK, Hagedorn HJ, Finney JW. Implementing evidencebased psychosocial treatment in specialty substance use disorder care. Psychology of Addictive Behaviors. 2011;**25**:225

#### *Leadership Approaches to Developing an Effective Drug Treatment System DOI: http://dx.doi.org/10.5772/intechopen.91055*

[29] McGovern MP, Carroll KM. Evidence-based practices for substance use disorders. The Psychiatric Clinics of North America. 2003;**26**:991

[30] Guerrero EG, Padwa H, Fenwick K, Harris LM, Aarons GA. Identifying and ranking implicit leadership strategies to promote evidence-based practice implementation in addiction health services. Implementation Science. 2016;**11**:69. DOI: 10.1186/ s13012-016-0438-y

[31] Birken SA, Lee SYD, Weiner BJ, Chin MH, Chiu M, Schaefer CT. From strategy to action: How top managers' support increases middle managers' commitment to innovation implementation in healthcare organizations. Health Care Management Review. 2015;**40**:159

[32] Engle RL, Lopez ER, Gormley KE, Chan JA, Charns MP, Lukas CV. What roles do middle managers play in implementation of innovative practices? Health Care Management Review. 2016;**42**:14-27

[33] Birken SA, Lee SY, Weiner BJ. Uncovering middle managers' role in healthcare innovation implementation. Implementation Science. 2012;**2**(*2*7):28

[34] Schein EH, Schein P. Organizational Culture and Leadership. 5th ed. San Francisco: Jossey-Bass; 2017

[35] Gottfredson RK, Aguinis H. Leadership behaviors and follower performance: Deductive and inductive examination of theoretical rationales and underlying mechanisms. Journal of Organizational Behavior. 2017;**38**: 558-591. DOI: 10.1002/job.2152

[36] Avolio BJ, Gardner WL, Walumbwa FO, Luthans F, May DR. Unlocking the mask: A look at the process by which authentic leaders impact follower attitudes and

behaviors. The Leadership Quarterly. 2004;**15**:801-823

[37] Saboe KN, Taing MU, Way JD, Johnson RE. Examining the unique mediators that underlie the effects of different dimensions of transformational leadership. Journal of Leadership & Organizational Studies. 2015;**22**:175-186. DOI: 10.1177/1548051814561028

[38] Aarons GA, Sommerfeld DH. Leadership, innovation climate, and attitudes toward evidencebased practice during a statewide implementation. Journal of the American Academy of Child and Adolescent Psychiatry. 2012;**51**:423-431

[39] Dragoni L. Understanding the emergence of state goal orientation in organizational work groups: The role of leadership and multilevel climate perceptions. The Journal of Applied Psychology. 2005;**90**:1084-1095

[40] Michaelis B, Stegmaier R, Sonntag K. Shedding light on followers' innovation implementation behavior: The role of transformational leadership, commitment to change, and climate for initiative. Journal of Managerial Psychology. 2010;**25**:408-429

[41] Klein KJ, Sorra JS. The challenge of innovation implementation. The Academy of Management Review. 1996;**21**:1055-1080

[42] Klein KJ, Knight AP. Innovation implementation: Overcoming the challenge. Current Directions in Psychological Science. 2005;**14**:243-246

[43] Klein KJ, Conn AB, Sorra JS. Implementing computerized technology: An organizational analysis. The Journal of Applied Psychology. 2001;**86**:811-824

[44] Holahan PJ, Aronson ZH, Jurkat MP, Schoorman FD. Implementing computer technology: A multiorganizational test of Klein and Sorra's model. Journal of Engineering and Technology Management. 2004;**21**:31-50

[45] Dong L, Neufeld DJ, Higgins C. Testing Klein and Sorra's innovation implementation model: An empirical examination. Journal of Engineering and Technology Management. 2008;**25**:237-255

[46] Bandura A. Social Foundations of Thought and Action: A Social-Cognitive View. Englewood Cliffs: Prentice-Hall; 1986

[47] Schein EA. Organizational Culture and Leadership. 2nd ed. San Francisco: Jossey-Bass; 1992

[48] Wimbush JC, Shepard JM. Toward an understanding of ethical climate: Its relationship to ethical behavior and supervisory influence. Journal of Business Ethics. 1994;**13**:637-647

[49] Zohar D. The influence of leadership and climate on occupational health and safety. In: Hofmann DA, Tetrick LE, editors. Health and Safety in Organizations: A Multilevel Perspective. San Francisco: Jossey-Bass; 2003. pp. 201-230

[50] Zohar D, Luria G. Climate as a social-cognitive construction of supervisory safety practices: Scripts as proxy of behavior patterns. The Journal of Applied Psychology. 2004;**89**:322-333

[51] Guerrero EG, Khachikian T. Frimpoing JA, Howard LD, Kong Y, Hunter S. Drivers of continued implementation of cultural competence in substance use disorder treatment. Journal of Substance Abuse Treatment. 2019;**105**:5-11. DOI: 10.1016/j. jsat.2019.07.009

[52] Delphin-Rittmon M, Andres-Hyman R, Flanagan EH, Ortiz J, Amer MM, Davidson L. Racial-ethnic differences in referral source, diagnosis, and length of stay in inpatient substance abuse treatment. Psychiatric Services. 2012;**63**:612-615

[53] Proctor E, Ramsey AT, Brown MT, et al. Training in implementation practice leadership (TRIPLE): Evaluation of a novel practice change strategy in behavioral health organizations. Implementation Science. 2019;**14**:66. DOI: 10.1186/ s13012-019-0906-2

[54] Gothard S, Austin MJ. Leadership succession planning: Implications for nonprofit human service organizations. Administration in Social Work. 2013;**37**(3):272-285. DOI: 10.1080/03643107.2012.684741
