Gender differences in client–provider relationship as active ingredient in substance abuse treatment

The client–provider relationship is increasingly evaluated as an active ingredient in the delivery of substance abuse treatment services. This study examines gender differences in client–provider relationship as an important treatment ingredient affecting retention in treatment and reduced post-treatment substance use. The study uses data collected for the National Treatment Improvement Evaluation Study (NTIES), a prospective, cohort study of U.S. substance abuse treatment programs and their clients. Data on individual characteristics were collected at the pre-treatment interview; on client–provider relationship and services received at treatment exit; and on post-treatment drug use at 12 months post-treatment. The analytic sample consists of 3027 clients from 59 service delivery units (1922 men and 1105 women). Structural equation modeling (SEM) was used to assess the structural relations and causal connections between relationship and service variables and treatment outcome variables. Results indicate that a positive client–provider relationship is related directly to longer duration and reduced post-treatment drug use for the total sample and for men analyzed separately. For women, a positive client–provider relationship was related directly to treatment duration and only indirectly to reduced post-treatment drug use. The findings point to the significance of including client–provider relationship in service delivery models – both as a therapeutic element as well as an element facilitative of matching services to specific client needs.     

Need-service matching in substance abuse treatment: Racial/ethnic differences

This study examines the impact of ancillary health and social services matched to client needs in substance abuse treatment for African Americans, Latinos and Whites. The study uses data collected from 1992 to 1997 for the National Treatment Improvement Evaluation Study, a prospective cohort study of substance abuse treatment programs and their clients. The analytic sample consists of 3142 clients (1812 African Americans, 486 Latinos, 844 Whites) from 59 treatment facilities. Results show that racial/ethnic minorities are underserved compared to Whites in the substance abuse service system. Different racial/ethnic groups come into treatment with distinct needs and receive distinct services. Although groups respond differentially to service types, substance abuse counseling and matching services to needs is an effective strategy both for retaining clients in treatment and for reducing post-treatment substance use for African Americans and Whites. Receipt of access services was related to reduced post-treatment substance use for Latinos. Study findings are relevant to planning special services for African Americans and Latinos.     

Enhancing Health-Conscious Behaviors Among Clients in Substance Abuse Treatment Programs

The physical health of substance abuse clients significantly deteriorates because of the client’s prolonged abuse of alcohol and other drugs and accompanying behaviors. The purposes of this study are (a) to understand how substance abuse clinicians think about the health needs of their clients, (b) to identify the mechanisms through which clinicians seek to enhance health-conscious behaviors among their clients, and (c) to identify how substance abuse clinicians view their role in enhancing health-conscious behaviors among their clients. A qualitative study was conducted using in-depth, semistructured interviews with substance abuse clinicians (N = 16) from 4 substance abuse treatment centers. Using the theory of planned behavior as a framework for understanding the promotion of health-conscious behaviors in substance abuse treatment, the findings suggest that substance abuse clinicians are capable of enhancing health-conscious behaviors among clients in substance abuse programs.     

Examination of the Role of Therapeutic Alliance,Treatment Dose,and Treatment Completion in the Effectiveness of The Seven Challenges

Adolescent alcohol and illicit drug (AOD) use is a major public health concern. This longitudinal study examines the effectiveness of The Seven Challenges in reducing adolescent substance use and mental health problems, as well as the process by which it is effective. Participants were 89 adolescents (72 male, 17 female) enrolled in a 3 month intensive outpatient adolescent substance abuse treatment program using The Seven Challenges and who provided self-report data at pre- and post-treatment. Results indicated that The Seven Challenges was effective at increasing the number of days refrained from using AOD, reducing use of tetrahydrocannabinol (THC) and other drugs, and reducing substance use problems and internal mental distress. Results also indicated that The Seven Challenges drug counselors effectively established and maintained therapeutic alliance but this seems to not play a role in the effectiveness of The Seven Challenges. Both treatment dose and completion played a role in the effectiveness of The Seven Challenges; they were both positively related to post-treatment days refrained from AOD use, and negatively related to days of THC use, substance use problems, and internal mental distress. However, the strength of the influence of treatment completion was stronger when treatment dose was low than when it was high. Despite a small sample and other limitations, findings add to existing literature that suggests that The Seven Challenges is an effective substance abuse treatment for adolescents. Furthermore, findings suggest that adolescent substance abuse treatment should focus on clients meeting pre-determined program goals as well as on dose.     

Alcohol Use and Prior Substance Abuse Treatment in Relation to Gambling Problem Severity and Gambling Treatment Outcome

Recent research has made it clear that problematic gambling is often accompanied by problematic alcohol use. Unfortunately, little is known about the nature of this association, especially as it relates to gambling treatment outcome. The purpose of this study is to explore the effect of current alcohol use level and previous substance abuse treatment on the symptoms of a large cohort of pathological gamblers as well as on their response to treatment for pathological gambling. The sample included 464 men and 301 women recruited at six gambling treatment programs in Minnesota. Gambling treatment patients were assessed on a number of gambling problem severity and related clinical variables using the Gambling Treatment Outcome Monitoring System (GAMTOMS). Patients with frequent alcohol use had greater gambling involvement at baseline than infrequent alcohol users. Patients with a previous history of substance abuse treatment had more severe psychosocial problems, ostensibly resulting from their gambling behavior, than patients without past substance abuse treatment. A MANOVA with repeated measures showed that neither pretreatment alcohol use, nor past substance abuse treatment exerted significant effects on gambling treatment outcome. While the level of pretreatment alcohol use and a history of substance abuse treatment are markers for greater gambling problem severity, treatment outcome for pathological gambling was not adversely impacted by these variables.     

The role of social isolation of elders in recidivism of self-neglect cases at San Francisco Adult Protective Services

This study examined the relationship between social isolation of elders and recidivism of self-neglect cases at San Francisco Adult Protective Services. Of secondary interest was an examination of other risk factors: mental health concerns, cognitive deficits, and substance/alcohol abuse. A secondary chart review was conducted on 704 elder clients with confirmed cases of self-neglect in 2004. Bivariate and multivariate analyses showed a positive relationship between substance/ alcohol abuse and recidivism, and a negative relationship between cognitive decline and recidivism. No significant relationships were found for social isolation or mental health concerns and recidivism. This study supports previous research suggesting significant relationships between substance abuse and self-neglect, further demonstrating a need for more substance/alcohol abuse programs for elders.     

An exploration of the effect of on-site 12-step meetings on post-treatment outcomes among polysubstance-dependent outpatient clients

Rates of return to active substance use after addiction treatment tend to be high; participation in 12-step fellowships (e.g., Alcoholics Anonymous) reduces relapse rates but many clients do not attend or attend for a short period only. This quasi-experimental study uses repeated measurement to explore the role of presence/absence of on-site 12-step meetings during treatment on post-treatment outcomes. Polysubstance-dependent clients (N = 219) recruited at a program with and one without 12-step on-site, were followed for one year post-treatment. On-site 12-step enhanced 12-step attendance, especially during treatment, and predicted continuous abstinence for the post-treatment year. Holding 12-step meetings on-site is a low-cost strategy that programs should consider to foster post-treatment remission maintenance.     

An evaluation of substance abuse aftercare program for homeless women with children using confounding variable-control design

An outcome evaluation of a substance abuse aftercare program for homeless women with children was conducted using confounding variable-control evaluation design. The confounding variables are chosen from pre-treatment and other contextual variables of the clients that are known to have significant influence on the program outcome, but those that could not have been influenced a priori by the client involvement in in-treatment program activity at Transition House (TH). The latter is the independent variable of this evaluation design. The pre-treatment variables are measured by severity of alcohol and other drug (AOD) problems of the clients, their mental health status, age, and their job status before enrollment in the program. The contextual confounding variables are composed of family and social support available to the clients before and during recovery. While applying multiple regression analysis, we were able to explain 50.8% of the total variance in program outcome by four pre-treatment variables. By adding two contextual variables of family and social support, the total variance in program outcome explained is increased to 64.1%. Finally, by adding the degree of client involvement in in-treatment program activity, we were able to augment the total variance of the program outcome to 69.7%. By estimating the changed variance of program outcome by the in-treatment program activity during the final step, controlling for all other variables previously entered, we were able to establish that client involvement in in-treatment program had unique and positive impact on the program outcome distinct from those explained by the confounding variables. The additional variance uniquely added by in-treatment program activity is 5.6% (p < .001). It has been determined that the degree of client involvement in in-treatment program had positive and systematic impact on the program outcome.     

Cross-system data linkage for treatment outcome evaluation: lessons learned from the California Treatment Outcome Project

Using administrative data to evaluate health care outcomes has become increasingly common, but the reliability and validity of outcome measures based on cross-system data linkage have been little scrutinized. Applying a deterministic data matching methodology, we linked 6545 Californians admitted to 43 substance abuse treatment programs between 2000 and 2001 to administrative data acquired from three state agency databases. We compared self-reported treatment outcome measures to equivalent measures derived from official records on motor vehicle driving incidents, criminal history, and mental health services utilization. Administrative data provided analogous results in some measures (e.g., percent of people using mental health services, percent ever arrested) and more accurate results in others (e.g., frequency of service utilization, and frequency of arrests). Similar to findings based on the interview data, the administrative data also revealed improvements in several domains 1-year post-treatment compared to 1-year pre-treatment. Experiences with data linkage procedures and strategies for enhancing record linkage accuracy are discussed. Findings illustrate the value of using administrative records for substance abuse treatment outcome evaluation, while highlighting areas for improvement for future cross-system data linkage efforts.     

Abstinence-Only: Are You Not Working the Program or Is the Program Not Working for You?

Low retention rates are common in substance use treatment programs. The dominant model of service delivery in the United States is abstinence-only, a high-threshold service delivery model requiring abstinence. What “doesn’t work” for the client—from the client point of view—is an overlooked source of insight about client engagement and disengagement. We report client counter-narratives about the choice to disengage from abstinence-based services, shifting from a story of “dropouts” to one of self-respect. Understanding why clients choose to disengage from treatment can help us as practitioners to “meet clients where they are” and enhance engagement in substance abuse treatment.     

The Influence of Substance Dependence and Mood Disorders on Outcome from Pathological Gambling: Five-Year Follow-Up

A prospective study of the role of comorbid substance abuse and dependence and mood disorders in the outcome from pathological gambling. A naturalistic sample of pathological gamblers who had recently quit gambling (N = 101) was followed and data were available for 83% of participants at 3 months, 80% at 12 months, and 52% at 5 years. Those participants with a drug diagnosis during their lifetime were less likely to have a minimum 3 month period of abstinence, and those who had been involved in gambling treatment were more likely to have a minimum 12 months of continuous abstinence. Lifetime gambling problem severity and involvement in gambling treatment were most commonly associated with a shorter time to achieving a period of abstinence of any length. Lifetime history of a mood disorder also predicted a longer time to reach a minimum 3 months of continuous abstinence. Both gambling treatment and an alcohol diagnosis follow up predicted an increase in the odds of experiencing a relapse from a minimum 6 month period of abstinence. Overall, comorbid mental health disorders are predictive of shorter term but not longer term outcome.     

Oxford house: a review of research and implications for substance abuse recovery and community research

After treatment for substance abuse, whether it is in hospital-based treatment programs, therapeutic communities, or recovery homes, many patients return to former high-risk environments or stressful family situations. Returning to these settings without a network of people to support abstinence increases chances of a relapse. As a consequence, substance abuse recidivism following treatment is high for both men and women. Alternative approaches need to be explored, and there are some promising types of recovery homes. From a public health perspective, a series of studies conducted at DePaul University suggests that one type of recovery home for alcohol abuse recovery has much potential. For example, within this self-help communal living setting, recovering alcoholics were able to maintain employment, thereby reducing their need for government subsidies. Maintaining employment for recovering alcoholics may promote increased personal responsibility, which may impact self-efficacy beliefs. These pilot studies, then, raised both theoretical and practical issues needing further evaluation.     

Internet-Based Interventions for Addictive Behaviours: A Systematic Review

Internet-based interventions have emerged as a new treatment and intervention modality for psychological disorders. Given their features of treatment flexibility, anonymity and confidentiality, this modality may be well suited in the management of addictive behaviours. A systematic literature review of the effectiveness and treatment outcomes of Internet-based interventions for smoking cessation, problematic alcohol use, substance abuse and gambling was performed. Studies were included if they met the following criteria: clients received a structured therapeutic Internet-based intervention for a problematic and addictive behaviour; included more than five clients; effectiveness was based on at least one outcome; outcome variables were measured before and immediately following the interventions; had a follow-up period; and involved at least minimal therapist contact over the course of the program. Sixteen relevant studies were found; nine addressed the effects of Internet-based interventions on smoking cessation, four on gambling, two on alcohol and one on opioid dependence. All studies demonstrated positive treatment outcomes for their respective addictive behaviours. The current review concluded that Internet-based interventions are effective in achieving positive behavioural change through reducing problematic behaviours. This mode of therapy has been found to have the capacity to provide effective and practical services for those who might have remained untreated, subsequently reducing the barriers for help-seekers. This in turn provides imperative information to treatment providers, policy makers, and academic researchers.     

Substance Use and Mental Health Severity Among LGBTQ Individuals Attending Minnesota Model-Based Residential Treatment

This administrative data analysis examined substance use and mental health severity among a sample of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals receiving residential treatment for an alcohol or drug use disorder. LGBTQ were statistically compared to heterosexual patients on a number of variables, including frequency and amount of pretreatment alcohol use, frequency of pretreatment illicit drug use, co-occurring Axis I mental health diagnoses, and past history of physical or sexual abuse. LGBTQ patients exhibited significantly greater severity on nearly all variables, suggesting a strong relationship between clinical severity and being a sexual minority. This study also found a relationship between patient gender and the pattern of differences between LGBTQ and heterosexual patients. These results replicate and extend those of studies examining LGBTQ in the general population and suggest opportunities for development of alcohol/drug treatment approaches that address the unique needs of LGBTQ.     

Physical Activity as a Helpful Adjunct to Substance Abuse Treatment

ABSTRACT

While limited research exists on the topic of physical activity as an adjunct to substance abuse treatment, a review of relevant multidisciplinary literature indicates a logical rationale for its potential benefits to recovery from addiction. This article provides an overview of common variables that contribute to addictive disease and summarizes the relationship of regular physical activity to improvements on many of these variables. The stages of change from the Transtheoretical Model (TTM, Prochaska & DiClemente, 1982; Prochaska & Velicer, 1997) are described in the context of effectively matching clients in substance abuse therapy to interventions that may include physical activity. Finally, important practical suggestions for implementing physical activity as a useful adjunct to substance abuse treatment are provided.     

Religiosity as a Predictor of Successful Post-Treatment Abstinence for African-American Clients

ABSTRACT

The purpose of this study was to examine the role of religiosity as a predictor of post-treatment abstinence. A sample of 96 African-American clients receiving community-based outpatient alcoholism treatment were interviewed at treatment entry and three months later. Achieving complete abstinence was predicted from client gender and 17 other predictors, including 6 substance-related factors, 7 psychosocial and health variables, and 4 religiosity/spirituality measures. Bivariate analyses showed that abstainers drank less prior to treatment, had more prior formal treatment and AA involvement, practiced their religion more regularly, and scored higher on measures of both spirituality and extrinsic religiosity. In addition, women were more likely to achieve abstinence. Forward entry binary logistic regression revealed that, controlling for client gender and pre-treatment consumption, only regular practice of one's religion/faith significantly predicted abstinence. Recommendations include (1) the need for research to evaluate if the current findings can be generalized across race/ethnicity and religious affiliation and (2) directing more attention to clients' religiosity in alcoholism treatment.     

A follow-up study of homeless women

This article presents an in-depth analysis of the changes observed in 25 homeless women with drug and alcohol abuse problems participating in a case management program. Participation in the program ranged from 6 to 44 months. Thirty-two percent of all participants' situations were considered to have improved, while 20% remained stable. Less improvement was noted in the situations of women followed for 3 years or more (14.3% improved, 28.6% stable). Domains showing the most improvement were housing, financial situation, and substance abuse. Deterioration was primarily attributable to physical and mental health problems. These findings could indicate that although a case management program can initially contribute to improving the living conditions of its clients, acquisitions are difficult to maintain over an extended period. Health and substance abuse play a crucial role in the deterioration process.     

Sexual victimization and substance abuse in psychiatrically hospitalized adolescents

This article investigates the relationship between substance abuse and sexual abuse in a population of 260 psychiatrically hospitalized adolescents. Seven hypotheses are set forth to test a model that uses parental alcohol abuse, sexual abuse status, and gender as exogenous variables, perceived benefit of alcohol or drugs as an endogenous mediating variable, and substance abuse as the dependent variable. Using these variables, a path model was constructed and revised based on empirical testing. The revised model achieved an adjusted R2 of .38, thus explaining 38 percent of the variance in this sample's abuse of alcohol or drugs. The model suggests that within clinical populations, sexually abused adolescents should be screened for substance abuse, and attention should be given to parental alcohol abuse as well as the degree to which adolescents perceive benefits from their alcohol or drug use.     

Comorbid Substance Abuse and Mental Illness

Abstract

Literature concerning assessment and treatment of comorbid substance abuse and mental illness is reviewed. Currently, comorbidity is under-diagnosed and dually diagnosed clients are under-served. Those clients, who are so diagnosed, are most often offered dichotomous parallel or serial interventions. However, research suggests that an integrated approach is preferable. Enhanced training of mental health and substance abuse professionals is urgently needed as is further research concerning the efficacy of various treatment modalities. Improved identification and treatment of comorbidity may reduce the revolving door effect among these individuals and thereby lower health care costs.     

Effects of Substance Abuse Central Intake on Treatment and Justice Costs

ABSTRACT

The cost-benefits of a central intake intervention for substance abuse treatment referrals were demonstrated using a transaction cost analysis on two cohorts of participants during the three-year initiative. Costs for clients receiving central intake services were compared with those just prior to the intervention's implementation. In order to study the relationship between substance abuse treatment costs and avoided criminal justice costs, data from three administrative data sets were used. Results indicate that clients receiving the central intake intervention had approximately a 58 percent decrease in costs compared to clients not receiving the intervention. The initiative produced opportunity cost savings to treatment, court, and correctional systems, with completion being crucial to opportunity cost savings.