Measuring substance abuse program treatment orientations: the Drug and Alcohol Program Treatment Inventory

Drug and alcohol treatment providers' views about the disease model of addiction and its impact on clinical practice: A systematic review

ISSUES

Addiction treatment providers' views about the disease model of addiction (DMA), and their contemporary views about the brain disease model of addiction (BDMA), remain an understudied area. We systematically reviewed treatment providers' attitudes about the DMA/BDMA, examined factors associated with positive or negative attitudes and assessed their views on the potential clinical impact of both models.

APPROACH

Pubmed, EMBASE, PsycINFO, CINAHL Plus and Sociological Abstracts were systematically searched. Original papers on treatment providers' views about the DMA/BDMA and its clinical impact were included. Studies focussing on tobacco, behavioural addictions or non-Western populations were excluded.

KEY FINDINGS

The 34 included studies were predominantly quantitative and conducted in the USA. Among mixed findings of treatment providers' support for the DMA, strong validity studies indicated treatment providers supported the disease concept and moral, free-will or social models simultaneously. Support for the DMA was positively associated with treatment providers' age, year of qualification, certification status, religious beliefs, being in recovery and Alcoholics Anonymous attendance. Greater education was negatively associated with DMA support. Treatment providers identified potential positive (e.g. reduced stigma) and negative (e.g. increased sense of helplessness) impacts of the DMA on client behaviour.

IMPLICATIONS/CONCLUSION

The review suggests treatment providers may endorse disease and other models while strategically deploying the DMA for presumed therapeutic benefits. Varying DMA support across workforces indicated service users may experience multiple and potentially contradictory explanations of addiction. Future policy development will benefit by considering how treatment providers adopt disease concepts in practice.

Randomized clinical trial of matching client alcohol use disorder severity and level of cognitive functioning to treatment setting: A partial replication and extension

In a tightly controlled, clinical research environment, Rychtarik et al. (2000) found that individuals with an alcohol use disorder (AUD) benefited more from inpatient (IP) than outpatient care, if they presented with high alcohol problem severity and/or low cognitive functioning. This study sought to (a) validate and extend these findings within the uncontrolled environment of a community-based treatment center and (b) test whether inpatients had fewer days of involuntary abstinence (e.g., incarcerations), controlling for differences in treatment expectancy across care settings. Clients (N = 176) with an AUD were deterministically assigned to inpatient-need group (needs IP = high severity and/or low cognitive functioning; no need for IP = neither high severity nor low cognitive functioning). Within need group, participants were randomly assigned to 21 days of routine inpatient or outpatient care, plus 6 months of continuing care. Primary outcomes of percentage of days abstinent (PDA), monthly point prevalence abstinence (PPA), and drinks per drinking day (DDD), and the secondary outcome of involuntary abstinence were assessed over 18 months. Among high-severity participants, inpatients significantly reduced DDD, and outpatients did not. Neither problem severity nor cognitive functioning moderated other setting effects. Treatment expectancy, assessed after being informed of scheduled setting, was higher among inpatients than outpatients. High-expectancy inpatients maintained the highest PDA throughout follow-up, had the highest PPA for most of follow-up, and delayed peak prevalence of involuntary abstinence by 6 months. In sum, the Alcohol Problem Severity × Setting interaction on DDD appears robust. The potential moderating role of expectancy will warrant further study. (PsycINFO Database Record

Smoking Cessation and Adolescent Treatment Response With Comorbid ADHD

Minors entering treatment for alcohol and other drug (AOD) use disorders tend to smoke at high rates, and many have comorbid attention deficit hyperactivity disorder (ADHD). Clear-air laws force patients to refrain from smoking on the premises of AOD treatment facilities, which may hinder the progress of treatment-seeking populations who smoke and struggle with ADHD comorbidity in particular. This study explores clinical characteristics associated with smoking among youths presenting for residential treatment, clinical characteristics associated with smoking cessation, and the impact of smoking cessation with ADHD comorbidity on AOD treatment response. Participants were 195 adolescents (52% female, aged 14-18 years) court-referred to residential treatment. Data were collected at intake, prospectively each week for the 10-week treatment period, and at discharge. Two-thirds (67%) of the enrollment sample entered treatment smoking half a pack a day on average, a large proportion (50%) of which did not smoke during treatment. ADHD patients were more likely to smoke before and during treatment except for those who got active in service and step-work. Quitting smoking did not adversely affect AOD outcomes and was associated with better prognosis of lowered AOD cravings for youths with and without ADHD. Smoking cessation during adolescent AOD treatment is recommended with provision of pharmaceutical and/or behavioral modalities that reduce nicotine withdrawal.

Religiosity as a Predictor of Adolescents' Substance Use Disorder Treatment Outcomes

BACKGROUND

A growing body of research on adults with substance use disorders (SUDs) suggests that higher levels of religiosity and/or spirituality are associated with better treatment outcomes. However, investigation into the role of religiosity and spirituality in adolescent SUD treatment response remains scarce. The present study examines religiosity as a predictor of treatment outcomes in an adolescent sample, with alcohol/other drug problem recognition as a hypothesized moderator of this relationship. Problem recognition was selected as a moderator in an attempt to identify a subset of adolescents who would be more likely to use religious resources when attempting to change their substance use.

METHODS

One hundred twenty-seven outpatient adolescents aged 14 to 19 (Mage=16.7, SD=1.2, 24% female) were followed for 1 year after treatment intake. Growth curve analyses were used to assess the impact of baseline religiosity and problem recognition on subsequent abstinence rates, drug-related consequences, and psychological distress.

RESULTS

On average, abstinence did not change significantly during the follow-up period, whereas drug-related consequences and psychological distress decreased significantly. Religiosity did not predict changes in abstinence or psychological distress over time. Religiosity did predict reductions in drug-related consequences over time (b=-0.20, t=-2.18, P=.03). However, when problem recognition was added to the model, the impact of religiosity on consequences became nonsignificant, and there was no interaction between religiosity and problem recognition on consequences.

CONCLUSIONS

The main hypothesis was largely unsupported. Possible explanations include that the sample was low in religiosity and few participants were actively seeking sobriety at treatment intake. Findings suggest adolescent outpatients with SUD may differ from their adult counterparts in the role that religiosity plays in recovery.

Listening to youth: Adolescents' reasons for substance use as a unique predictor of treatment response and outcome

National efforts have focused on improving adolescent substance use disorder (SUD) treatment outcomes, yet improvements remain modest. Because adolescents are noteworthy for heterogeneity in their clinical profiles, treatment might be enhanced by the identification of clinical subgroups for which interventions could be more effectively tailored. Some of these subgroups, such as those based on abstinence motivation, substance involvement, and psychiatric status are promising candidates. This study examined the unique predictive utility of adolescents' primary reason for alcohol and other drug use. Adolescent outpatients (N = 109; 27% female, aged 14-19) were assessed at treatment intake on their reason for substance use, as well as demographic, substance use, and clinical variables, and reassessed at 3, 6, and 12 months. Reason for use fell into two broad domains: using to enhance a positive state (positive reinforcement [PR]; 47% of youth) and using to cope with a negative state (negative reinforcement [NR]; 53% of youth). Compared with PR patients, NR patients were significantly more substance involved, reported more psychological distress, and had a more extensive treatment history. It is important to note that NR patients showed a significant treatment response, whereas PR patients showed no improvement. PR-NR status also uniquely predicted treatment response and outcome independent of a variety of other predictors, including abstinence motivation, self-efficacy, coping, and prior treatment. Adolescents' primary reason for substance use may provide unique clinical information that could inform treatment planning and patient-treatment matching.

Stimulant abuser groups to engage in 12-step: a multisite trial in the National Institute on Drug Abuse Clinical Trials Network

AIMS

The study evaluated the effectiveness of an 8-week combined group plus individual 12-step facilitative intervention on stimulant drug use and 12-step meeting attendance and service.

DESIGN

Multisite randomized controlled trial, with assessments at baseline, mid-treatment, end of treatment, and 3- and 6-month post-randomization follow-ups (FUs).

SETTING

Intensive outpatient substance treatment programs.

PARTICIPANTS

Individuals with stimulant use disorders (n = 471) randomly assigned to treatment as usual (TAU) or TAU into which the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention was integrated.

MEASUREMENTS

Urinalysis and self-reports of substance use and 12-step attendance and activities.

INTERVENTION

Group sessions focused on increasing acceptance of 12-step principles; individual sessions incorporated an intensive referral procedure connecting participants to 12-step volunteers.

FINDINGS

Compared with TAU, STAGE-12 participants had significantly greater odds of self-reported stimulant abstinence during the active 8-week treatment phase; however, among those who had not achieved abstinence during this period, STAGE-12 participants had more days of use. STAGE-12 participants had lower Addiction Severity Index Drug Composite scores at and a significant reduction from baseline to the 3-month FU, attended 12-step meetings on a greater number of days during the early phase of active treatment, engaged in more other types of 12-step activities throughout the active treatment phase and the entire FU period, and had more days of self-reported service at meetings from mid-treatment through the 6-month FU.

CONCLUSIONS

The present findings are mixed with respect to the impact of integrating the STAGE-12 intervention into intensive outpatient drug treatment compared with TAU on stimulant drug use. However, the results more clearly indicate that individuals in STAGE-12 had higher rates of 12-step meeting attendance and were engaged in more related activities throughout both the active treatment phase and the entire 6-month FU period than did those in TAU.

Youth recovery contexts: the incremental effects of 12-step attendance and involvement on adolescent outpatient outcomes

BACKGROUND

A major barrier to youth recovery is finding suitable sobriety-supportive social contexts. National studies reveal most adolescent addiction treatment programs link youths to community 12-step fellowships to help meet this challenge, but little is known empirically regarding the extent to which adolescents attend and benefit from 12-step meetings or whether they derive additional gains from active involvement in prescribed 12-step activities (e.g., contact with a sponsor and other fellowship members). Greater knowledge in this area would enhance the efficiency of clinical continuing care recommendations.

METHODS

Adolescent outpatients (N = 127; M age 16.7; 75% male; 87% white) enrolled in a naturalistic study of treatment effectiveness were assessed at intake and 3, 6, and 12 months later using standardized assessments. Mixed-effects models, controlling for static and time-varying confounds, examined the concurrent and lagged effects of 12-step attendance and active involvement on abstinence over time.

RESULTS

The proportion attending 12-step meetings was relatively low across follow-up (24 to 29%), but more frequent attendance was independently associated with greater abstinence in concurrent and, to a lesser extent, lagged models. An 8-item composite measure of 12-step involvement did not enhance outcomes over and above attendance, but separate components did; specifically, greater contact with a 12-step sponsor outside of meetings and more verbal participation during meetings.

CONCLUSIONS

The benefits of 12-step participation observed among adult samples extend to adolescent outpatients. Community 12-step fellowships appear to provide a useful sobriety-supportive social context for youths seeking recovery, but evidence-based youth-specific 12-step facilitation strategies are needed to enhance outpatient attendance rates.

Influence of religiosity on 12-step participation and treatment response among substance-dependent adolescents

OBJECTIVE

Religious practices among adults are associated with more 12-step participation which, in turn, is linked to better treatment outcomes. Despite recommendations for adolescents to participate in mutual-help groups, little is known about how religious practices influence youth 12-step engagement and outcomes. This study examined the relationships among lifetime religiosity, during-treatment 12-step participation, and outcomes among adolescents, and tested whether any observed beneficial relation between higher religiosity and outcome could be explained by increased 12-step participation.

METHOD

Adolescents (n = 195; 52% female, ages 14-18) court-referred to a 2-month residential treatment were assessed at intake and discharge. Lifetime religiosity was assessed with the Religious Background and Behaviors Questionnaire; 12-step assessments measured meeting attendance, step work (General Alcoholics Anonymous Tools of Recovery), and Alcoholics Anonymous (AA)/Narcotics Anonymous (NA)-related helping. Substance-related outcomes and psychosocial outcomes were assessed with toxicology screens, the Adolescent-Obsessive Compulsive Drinking Scale, the Children's Global Assessment Scale, and the Narcissistic Personality Inventory.

RESULTS

Greater lifetime formal religious practices at intake were associated with increased step work and AA/NA-related helping during treatment, which in turn were linked to improved substance outcomes, global functioning, and reduced narcissistic entitlement. Increased step work mediated the effect of religious practices on increased abstinence, whereas AA/NA-related helping mediated the effect of religiosity on reduced craving and entitlement.

CONCLUSIONS

Findings extend the evidence for the protective effects of lifetime religious behaviors to an improved treatment response among adolescents and provide preliminary support for the 12-step proposition that helping others in recovery may lead to better outcomes. Youth with low or no lifetime religious practices may assimilate less well into 12-step-oriented treatment and may need additional 12-step facilitation, or a different approach, to enhance treatment response.

AOD treatment agencies: does religious affiliation influence service delivery?

INTRODUCTION AND AIMS

Religious organisations have been involved in delivering alcohol and other drug (AOD) services since Australian colonial times and are a familiar presence in the AOD sector. However, there is concern in some sectors that AOD services delivered by religious organisations might be influenced by religious ideology, at the expense of evidence-based service provision.

DESIGN AND METHODS

A national, cross-sectional survey of non-government AOD agencies was undertaken using a mailed questionnaire. All non-government AOD agencies in Australia, providing at least one face-to-face specialist AOD service, were invited to participate. Agency goals and activities were assessed using the Drug and Alcohol Program Treatment Inventory, which has eight distinct treatment orientations: 12-step, therapeutic community, cognitive behavioural therapy, psychodynamic, family, rehabilitation, dual diagnosis and medical.

RESULTS

There was a high degree of uniformity in treatment orientations with religiously affiliated agencies having similar goals and activities to non-religiously affiliated agencies. Cognitive behavioural therapy was most commonly provided and 12-step the least provided. Religiously affiliated agencies were significantly more likely to favour the 12-step orientation in both goals and activities.

DISCUSSION AND CONCLUSIONS

Concerns that the religious affiliation of non-government organisations might influence AOD service delivery in Australia appear to be overstated. Factors contributing to the observed uniformity of care may include a more strategic, federal approach; and an increasing emphasis on best practice within the sector. The lack of discernable differentiation between religiously affiliated and non-religiously affiliated non-government organisations may also be attributable to changes in the way services are delivered by many religious organisations.

Facilitating involvement in twelve-step programs

Twelve-step programs represent a readily available resource for individuals with substance use disorders. These programs have demonstrated considerable effectiveness in helping substance abusers achieve and maintain abstinence and improve their overall psychosocial functioning and recovery. Despite these positive benefits associated with increased involvement in twelve-step self-help programs, many substance abusers do not affiliate or do so for only a short period of time before dropping out. Because of this, clinicians and researchers have sought ways to increase involvement in such self-help groups by facilitating meeting attendance and engagement in other twelve-step activities. The present chapter reviews the impact of treatment program orientation and specific interventions designed to facilitate twelve-step program involvement, subsequent meeting attendance, engagement in twelve-step activities, and alcohol and drug use. The findings of studies evaluating these approaches indicate that it is possible to increase twelve-step involvement and that doing so results in reduced substance use. The results suggest that incorporating these evidence-based interventions into standard treatment programs may lead to improved outcomes.

Alcoholics Anonymous attendance following 12-step treatment participation as a link between alcohol-dependent fathers' treatment involvement and their children's externalizing problems

We investigated longitudinal associations between alcohol-dependent fathers' 12-step treatment involvement and their children's internalizing and externalizing problems (N = 125, M(age) = 9.8 +/- 3.1), testing the hypotheses that fathers' greater treatment involvement would benefit later child behavior and that this effect would be mediated by fathers' posttreatment behaviors. The initial association was established between fathers' treatment involvement and children's externalizing problems only, whereas Structural Equation Modeling (SEM) results supported mediating hypotheses. Fathers' greater treatment involvement predicted children's lower externalizing problems 12 months later, and fathers' posttreatment behaviors mediated this association: Greater treatment involvement predicted greater posttreatment Alcoholics Anonymous attendance, which in turn predicted greater abstinence. Finally, fathers' abstinence was associated with lower externalizing problems in children. Theoretical and practical implications of these findings are discussed.

Adolescents' participation in Alcoholics Anonymous and Narcotics Anonymous: review, implications and future directions

Youth treatment programs frequently employ 12-Step concepts and encourage participation in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). Since AA/NA groups are easily accessible at no charge and provide flexible support at times of high relapse risk they hold promise as a treatment adjunct in an increasingly cost-constricting economic climate. Yet, due to concerns related to adolescents' developmental status, skepticism exists regarding the utility of AA/NA for youth. This review evaluates the empirical evidence in this regard, identifies and discusses knowledge gaps, and recommends areas for future research. Searches were conducted in PsychINFO, Medline, relevant literature and by personal correspondence. Findings suggest youth may benefit from AA/NA participation following treatment, but conclusions are limited by four important factors: (1) a small number of studies; (2) no studies with outpatients; (3) existing evidence is solely observational; and (4) only partial measurement of the 12-Step construct. While surveys of adolescent SUD treatment programs indicate widespread clinical interest and application of adult-derived 12-Step approaches this level of enthusiasm has not been reflected in the research community. Qualitative research is needed to improve our understanding of youth-specific AA/NA barriers, and efficacy, comparative effectiveness, and process studies are still needed to inform clinical practice guidelines for youth providers.

Brief family treatment intervention to promote continuing care among alcohol-dependent patients in inpatient detoxification: a randomized pilot study

Alcohol-dependent patients in inpatient detoxification were randomized to treatment-as-usual (TAU) intervention or brief family treatment (BFT) intervention to promote continuing care postdetoxification. BFT consisted of meeting with the patient and an adult family member (in person or over the phone) with whom the patient lived to review and recommend potential continuing care plans for the patient. Results showed that BFT patients (n = 24) were significantly more likely than TAU patients (n = 21) to enter a continuing care program after detoxification. This was a medium to large effect size. In the 3 months after detoxification, days using alcohol or drugs (a) trended lower for treatment-exposed BFT patients who had an in-person family meeting than for TAU counterparts (medium effect), and (b) were significantly lower for patients who entered continuing care regardless of treatment condition (large effect).

TREATMENT STAFF REFERRALS, PARTICIPATION EXPECTATIONS, AND PERCEIVED BENEFITS AND BARRIERS TO ADOLESCENT INVOLVEMENT IN 12-STEP GROUPS

Adolescents treated for substance use disorders (SUD) appear to benefit from AA/NA participation. However, as compared to adults, fewer adolescents attend, and those who do attend do so less intensively and discontinue sooner. It is unknown whether this disparity is due to a lowered expectation for youth participation by the clinicians treating them, as they may adapt the adult-based model to fit a less dependent cohort, or whether recommendations are similar to those of clinicians who work with adults, and other factors are responsible. All clinical staff (N = 114) at five adolescent programs (3 residential, 2 outpatient) were surveyed anonymously about referral practices and other beliefs about 12-step groups. Staff rated AA/NA participation as very important and helpful to adolescent recovery and referral rates were uniformly high (M = 86%, SD = 28%). Desired participation frequency was over 3 times per week. The theoretical orientation and level of care of the programs influenced some results. Findings suggest lower adolescent participation in 12-step groups is not due to a lack of clinician enthusiasm or referrals, but appears to be due to other factors.

Longitudinal associations between fathers' heavy drinking patterns and children's psychosocial adjustment

Psychosocial adjustment in children of alcoholics (N = 114) was examined in the year before and at three follow-ups in the 15 months after their alcoholic fathers entered alcoholism treatment, testing the hypothesis that children's adjustment problems will vary over time as a function of their fathers' heavy drinking patterns. Three unique patterns of heavy drinking in alcoholic fathers were identified through cluster analysis. The results demonstrated significant and meaningful associations between these drinking patterns in fathers and adjustment problems in children over time. Overall, children whose fathers remained mostly abstinent following their treatment showed lowest and decreasing adjustment problems, while children whose fathers continued and increased heavy drinking following their treatment showed greatest and increasing adjustment problems over time.

Brief family treatment intervention to promote aftercare among male substance abusing patients in inpatient detoxification: A quasi-experimental pilot study

We developed a brief family treatment (BFT) intervention for substance abusing patients in inpatient detoxification to promote aftercare treatment post-detox. BFT consisted of meeting with the patient and a family member (spouse or parent) with whom the patient lived to review and recommend potential aftercare plans for the patient. A phone conference was used when logistics prevented an in-person family meeting. Results indicated that male substance abusing patients who received BFT (N=14), as compared with a matched treatment as usual (TAU) comparison group (N=14) that did not, showed a trend toward being more likely to enter an aftercare program and to attend more days of aftercare in the 3 months after detoxification. The magnitude of these differences favoring BFT over TAU was midway between a medium and a large effect size. Days using alcohol or drugs in the 3 months after detox were lower for treatment-exposed BFT patients who had an in-person family meeting than TAU counterparts (trend, medium effect), and for patients who entered aftercare regardless of treatment condition (significant large effect).

Participation in specific treatment components predicts alcohol-specific and general coping skills

This study identified which aspects of substance abuse treatment in community residential facilities (CRFs) were correlated with patients' post-treatment coping. A total of 2376 patients supplied demographic information and completed measures at baseline (coping and abstinence self-efficacy) and one year after treatment (coping, level of drug and alcohol use, and substance-related problems). Staff provided information about treatment orientation and patients' participation in treatment (e.g., life skills training, vocational counseling). The data were used to predict coping 1 year after treatment. As expected, higher levels of general approach coping and alcohol-specific coping and lower levels of general avoidance coping were associated with less 1-year alcohol and drug use and fewer drinking problems. Patients' greater level of participation in life skills counseling predicted more approach coping at 1 year. In addition, positive social relationships and participation in 12-step self-help groups predicted less general avoidance coping and more alcohol-specific coping at 1 year post-treatment. Life skills training, 12-step self-help groups, and enhancement of supportive relationships during CRF treatment for substance abuse are related to healthy coping. Future research should examine the effect of these components in less intensive programs and with women.

Theory-based active ingredients of effective treatments for substance use disorders

This paper describes four related theories that specify common social processes that protect individuals from developing substance use disorders and may underlie effective psychosocial treatments for these disorders: social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. It then provides an overview of the rationale and evidence for four effective psychosocial treatments for substance use disorders: motivational interviewing and motivational enhancement therapy, 12-step facilitation treatment, cognitive-behavioral treatment and behavioral family counseling, and contingency management and community reinforcement approaches. The presumed active ingredients of these treatments are described in terms of how they exemplify the social processes highlighted by the four theories. The identified common components of effective treatment include support, goal direction, and structure; an emphasis on rewards that compete with substance use, a focus on abstinence-oriented norms and models, and attempts to develop self-efficacy and coping skills. Several issues that need to be addressed to enhance our understanding of the active ingredients involved in effective treatment are discussed, including how to develop measures of these ingredients, how well the ingredients predict outcomes and influence conceptually comparable aspects of clients' life contexts, and how much their influence varies depending upon clients' demographic and personal characteristics.

Program structure, staff perceptions, and client engagement in treatment

A key goal of drug abuse treatment providers is getting their clients to engage and participate in therapeutic activities as a first step toward deriving longer-term benefits. Much research had focused on personal characteristics that relate to client engagement; program characteristics have received less attention. This study explored client and program differences in engagement ratings using data from a nationwide set of 94 outpatient drug-free treatment programs in a hierarchical linear model analysis. The results show that elements of program context, including structural features (e.g., smaller size and Joint Commission on the Accreditation of Healthcare Organizations/Commission on Accreditation of Rehabilitation Facilities accreditation) and staff's perceptions of personal efficacy, organizational climate, and communal workplace practices, relate to better overall client engagement. These findings add further evidence that treatment providers should also address the workplace environment for staff as part of quality improvement efforts.

Organizational characteristics of drug abuse treatment programs for offenders

This article examines the association between the organizational characteristics of drug abuse treatment programs for offenders and the provision of wraparound services and three types of treatment orientations. Data are from the National Criminal Justice Treatment Practices Survey, which was conducted with program directors (N = 217). A greater number of wraparound services provided were associated with inpatient treatment, specialized treatment facilities, community setting (vs. correctional), services provided for more types of client populations, college-educated staff, and planned treatment for > 180 days. Therapeutic community orientation was associated with prison-based treatment and specialized treatment facilities. Cognitive-behavioral therapy orientation was associated with higher perceived importance of community treatment, more perceived staff influence on treatment, and treatment for 91-180 days. The 12-step orientation was most strongly associated with having staff specialized in substance abuse. Study findings have implications for developing effective reentry programs for offenders that bridge correctional and community treatment.

Screening for cognitive functioning in psychiatric outpatients with schizophrenia, alcohol dependence, and dual diagnosis

Cognitive impairment is common to both schizophrenia and alcoholism. Despite increasing recognition that people with both disorders represent a problematic client group, little is known about the possible additive effect of a dual diagnosis upon impaired cognitive function. This study investigates impairment of cognitive functioning in patients with schizophrenia, alcohol dependence, or a dual diagnosis of schizophrenia and alcohol use disorder. It was hypothesised that patients with dual diagnosis would show greater cognitive impairment than those with a single diagnosis. The Mini-Mental State Examination (MMSE) and standardised measures of psychiatric health and substance use were administered to 120 community psychiatric patients with a diagnosis of schizophrenia, alcohol dependence and both conditions (dual diagnosis). Higher rates of cognitive impairment were found among dual diagnosis patients compared to the schizophrenia or alcohol patients. This was shown in age-adjusted measures of global functioning, and on the tests of language, reading and writing, and visuospatial construction. Despite its common usage, global MMSE scores were insensitive to the cognitive impairments typically found in these clinical groups. Where the MMSE is used as a screening tool, it is recommended that scores are adjusted for the effects of age.

Substance use disorder treatment programs in Switzerland and the USA: Program characteristics and 1-year outcomes

AIM

This study compared matched samples of substance use disorder (SUD) patients in Swiss and United States (US) residential treatment programs and examined the relationship of program characteristics to patients' substance use and psychosocial functioning at a 1-year follow-up.

DESIGN AND SETTING

The study used a prospective, naturalistic design and a sample of 10 public programs in the German-speaking part of Switzerland and 15 US public treatment programs.

PARTICIPANTS

A total of 358 male patients in Swiss programs were matched on age, marital status and education with 358 male patients in US programs. A total of 160 Swiss and 329 US patient care staff members also participated.

MEASUREMENT

Patients completed comparable inventories at admission, discharge and 1-year follow-up to assess their substance use and psychological functioning and receipt of continuing care. Staff members reported on program characteristics and their beliefs about substance use.

FINDINGS

Compared to Swiss patients, US patients had more severe substance use and psychological problems at intake and although they did not differ on abstinence and remission at follow-up, had somewhat poorer outcomes in other areas of functioning. Swiss programs were longer and included more individual treatment sessions; US programs included more group sessions and were more oriented toward a disease model of treatment. Overall, length of program, treatment intensity and 12-step orientation were associated with better 1-year outcomes for patients in both Swiss and US programs.

CONCLUSIONS

The sample of Swiss and US programs studied here differed in patient and treatment characteristics; however, in general, there were comparable associations between program characteristics and patients' 1-year outcomes. These findings suggest that associations between treatment processes and patients' outcomes may generalize from one cultural context to another.

Predictors of engagement in continuing care following residential substance use disorder treatment

BACKGROUND

Patients in intensive SUD programs who subsequently participate in continuing care for a longer interval have better outcomes than those who participate for a shorter interval. We sought to identify patient and program factors associated with duration of engagement in SUD continuing care after residential/inpatient treatment.

METHODS

Patients (n=3032) at 15 geographically diverse SUD residential treatment programs provided data on demographics, symptom patterns, recovery resources, and perceptions of treatment environment. We identified patient characteristics associated with the number of consecutive months of engagement in continuing care. We then consolidated and classified risk factors into an integrated model.

RESULTS

Being African American, having more SUD and psychiatric symptoms, more resources for recovery, and perceiving the treatment staff as being supportive were associated with longer engagement in continuing care. African Americans' engagement in continuing care was 17% longer than Caucasians'. The positive effect of being African American was partially mediated by having taken actions toward changing use, and by the presence of psychotic symptoms.

CONCLUSION

These results extend previous research on the predictors of continuing care engagement after residential SUD programs. Clinicians can use information about characteristics that put patients at risk for shorter engagement in continuing care to target patients who might benefit from interventions to increase engagement in continuing care.

A practical system for monitoring the outcomes of substance use disorder patients

Outcomes monitoring and management are receiving mounting attention because of increased emphasis on health care accountability and cost containment. Efficient, practical outcomes monitoring systems (OMSs) are crucial if health care system performance is to be determined and effective/cost-effective treatments are to be identified, but such practical monitoring systems generally are lacking. This article describes the features of such a system for monitoring the care received by, and the substance use and psychosocial outcomes of, patients treated for substance use disorders (SUDs) in the Department of Veterans Affairs (VA). In contrast to a 15-21% follow-up rate achieved by VA SUD program staff under a previously mandated system-wide monitoring system, the monitoring system used in this project achieved a 67% follow-up rate without paying patients for their participation. We provide data on patient characteristics and treatment outcomes, estimate the cost of implementing this type of monitoring system on a broad scale, and provide recommendations for OMSs in other large health care organizations.

Partner violence before and after individually based alcoholism treatment for male alcoholic patients

This study examined partner violence in the year before and the year after individually based, outpatient alcoholism treatment for 301 married or cohabiting male alcoholic patients and used a demographically matched nonalcoholic comparison sample. In the year before treatment, 56% of the alcoholic patients had been violent toward their female partner, 4 times the rate of 14% in the comparison sample. In the year after treatment, violence decreased significantly to 25% of the alcoholic sample but remained higher than in the comparison group. Among remitted alcoholics after treatment, violence prevalence of 15% was nearly identical to the comparison sample and half the rate among relapsed patients (32%). Thus, partner violence decreased after alcoholism treatment, and clinically significant violence reductions occurred for patients whose alcoholism was remitted after treatment.

Improving service delivery to the dually diagnosed in Los Angeles County

Service delivery to dually diagnosed individuals remains problematic in many communities because of entrenched administrative structures that maintain the separation of mental health and substance abuse treatment systems. This article describes efforts to improve service delivery to dually diagnosed individuals in Los Angeles County by increasing communication, coordination, and collaboration across the two treatment systems. Findings are presented on the relationships among program models of service delivery, treatment orientations of programs, and interactions with other service providers to the dually diagnosed. Results showed that drug treatment programs that adhered more closely to an integrated model of service delivery received more patient referrals from case management outreach teams and that programs with a stronger counseling approach to treatment had more linkages with other service providers. Knowledge gained from research on these differing models of service delivery can be combined with new clinical advances to improve service delivery to the dually diagnosed.

Individual and contextual predictors of involvement in twelve-step self-help groups after substance abuse treatment

Drawing on ecological and narrative theories of self-help groups, this study tests a multilevel model predicting self-help group involvement among male veterans who received inpatient substance abuse treatment. Following K. Maton (1993), the study moves beyond the individual-level of analysis to encompass variables in the treatment and post-treatment social ecology. Surveys administered to patients (N = 3,018) and treatment staff (N = 329) assessed these predictor domains and self-help group involvement 1 year after discharge. A hierarchical linear model fit to the data indicates that greater involvement in 12-step groups after discharge is predicted by the compatibility between personal and treatment belief systems. The implications of these findings for efforts to facilitate transitions between inpatient professional treatment and community-based self-help groups are discussed.

Staff beliefs about addiction treatment

In 1999, the National Institute on Drug Abuse established a researcher/provider partnership designed to test the effectiveness of research-based innovations in community-based treatment settings and facilitate the transfer of those innovations throughout the national treatment system. As a preliminary step in developing their local Clinical Trials Network, researchers and treatment providers within the Delaware Valley Node surveyed 317 staff members concerning their beliefs about addiction treatment. More than 80% of respondents supported increased use of research-based innovations, 12-step/traditional approaches, and spirituality in addiction treatment, while only 39% and 34%, respectively, endorsed the increased use of naltrexone and methadone maintenance. Also, 35% of respondents indicated that confrontation should be used more, and 46% agreed with discharging noncompliant patients. Individuals with more formal training tended to be less supportive of confrontation and more supportive of the increased use of medications. Implications for the clinical trials and technology transfer are discussed.

Drug treatment effectiveness: an examination of conceptual and policy issues

This paper discusses different concepts or views of what constitutes effective treatment for drug dependence and how these views are involved in policy decisions regarding treatment. The paper reviews the rise of evidence-based medicine, discusses the emergence of efficacy research, effectiveness research, and other types of outcome-based evaluations of drug user treatment, but notes that despite a growing consensus among researchers on the effectiveness of drug user treatment, substantial public skepticism about the value of treatment still exists in the United States. The paper argues that one of the primary reasons for the lack of public consensus in the United States is that there is wide disagreement over which type of problem drug dependence is and for whom it may be a problem. The paper reviews some of the most common models and their implications for evaluating effectiveness, and argues that it is the differences in perspective among these models that are at the heart of policy debate over drug treatment policy in the United States. The paper concludes that because evaluation research as currently practiced does not address these issues, its utility for policy purposes is limited in the American context.

Development of a "treatment program" descriptor: the addiction treatment inventory

This paper reviews the current literature on the definition and classification of drug and alcohol user treatment "programs," and provides a rationale for our approach to measuring the treatment programs in the Drug Evaluation Network System (DENS). The DENS gathers extensive background and recent status data on patients' drug, alcohol, psychiatric, medical, employment, legal, and family problems as they enter a sample of treatment programs throughout the country. The DENS recognized the need for descriptive information on important structural, organizational, and service delivery aspects of the programs in which those patients were treated. To this end, we present our efforts thus far in characterizing and monitoring "service delivery units" or "programs" that are sampled in the DENS system. Specifically, we present development of the Addiction Treatment Inventory (ATI), a standardized measurement instrument to characterize these service delivery units and their services.

Patient and program attributes related to treatment process indicators in DATOS

Patient ratings of their personal confidence in treatment and commitment to recovery were examined in a national sample of long-term residential, outpatient drug-free, and outpatient methadone programs. It was found that patients expressing greater confidence and commitment after 3 months of treatment generally began with higher motivation at intake, had formed better rapport with counselors, and attended counseling sessions more frequently. In addition, overall levels of patient involvement (as indicated by confidence and commitment) varied across programs; those programs with higher average involvement by patients used more social and public health services, maintained more consistent attendance at counseling sessions, and served patients who collectively had more similar kinds of needs. Thus, patient and program attributes both play a role in determining therapeutic engagement of persons who enter drug treatment.

Developing a national addiction treatment information system. An introduction to the Drug Evaluation Network System

The purpose of this article is to test the applicability and utility of the Drug Evaluation Network Study (DENS), a timely electronic information system that tracks trends in substance abuse treatment. This article examines existing large-scale data collection efforts, discusses the rationale and design of the DENS system, and presents results of the DENS pilot phase. Clinical staff from more than 40 service delivery units in five cities were trained to conduct intake assessments on laptop computers with the computerized Addiction Severity Index (ASI). The DENS computer system also included an automatic data transfer protocol to allow regular transmission of ASIs and other data to a central server at Treatment Research Institute. Descriptive information and discharge status were also collected. Several problems were encountered during the early stages of the pilot phase, including obtaining consecutive cases from treatment programs, computerization and software application, treatment staff turnover, and assuring quality of data. Data is presented on 4,300 adults entering drug and/or alcohol treatment at the nonrandomly selected DENS pilot programs between June 1996, and April 6, 1998. Various examples of how DENS data can be used are presented.

Measuring treatment process beliefs among staff of specialized addiction treatment services

In a survey conducted in Ontario, front-line staff of specialized addiction treatment services were asked to indicate the extent to which they believed 53 different treatment processes to be necessary for the effective treatment of people with alcohol and drug problems. Cognitive-behavioural processes were generally rated as almost essential for treatment to be effective. Other processes received mixed ratings, while confrontation and pharmacological treatment were, on average, rated as detrimental. Factor analysis identified three interpretable dimensions of beliefs (a) cognitive-behavioural, (b) disease, and (c) medication. A fourth dimension involved both psychodynamic and conditioning processes and did not clearly correspond with any known therapeutic approach. Scores on scales developed using items from these four dimensions were variously influenced by respondents age, education, place of work, and certification status. Two groups identified using cluster analysis differed primarily with respect to scores on the disease scale. Logistic regression analysis showed that age, certification status, and place of work were associated with membership in these groups. Implications for treatment system development and research are discussed.

Community residential program policies, services, and treatment orientations influence patients' participation in treatment

The study sought to identify community residential program characteristics that predict patients' participation in treatment and to examine the association between these characteristics, participation, and outcomes at discharge from treatment. A sample of 2,790 patients with substance abuse disorders was assessed at entry into and discharge from 87 community residential facilities (CRFs). The CRFs were assessed using a survey that obtained information about program size and staffing, policies and services, and treatment orientation. High expectations for patients' functioning, clear policies, structured programming, a high proportion of staff in recovery from substance abuse problems, and more emphasis on psychosocial treatment were associated with patients' participation in program services and activities. Higher expectations for functioning and a strong treatment orientation enhanced participation more among better functioning patients; program support and structure enhanced participation more among impaired patients. Participation in treatment independently predicted outcomes at discharge even after both patient and program characteristics were controlled. These findings show that community residential program policies, services, and treatment orientations play a key role in influencing patients' engagement in treatment, which, in turn, improves patients' outcomes at discharge.

Measuring treatment philosophy: a scale for substance abuse recovery programs

The assessment of the philosophy that guides substance abuse treatment programs has been a difficult subject to approach by those working in treatment research. Differing treatment philosophies are generally represented by multi-dimensional theoretical constructs that do not easily lend themselves to assessment by quantitative means. In the U.S., substance abuse treatment programs have been suggested as fitting into a disease (or medical) model, a social learning (or psychological) model, or a social community model in designing a treatment regime for clients. This paper presents a Social Model Philosophy Scale (SMPS) to classify the extent to which a given treatment program follows a social model approach to treatment. The final version of the SMPS (available from the first author) contains 33 questions for use in residential programs, divided into six conceptual domains: physical environment, staff role, authority base, view of substance abuse problems, governance, and community orientation. Overall internal reliability is high (alpha = .92), with subscale alphas ranging between .57 and .79. Test-retest analyses showed that the information obtained from the SMPS is consistent across time, administrators, and respondents. In addition, the SMPS is brief and easy to administer. Methodology used in item creation and final item selection is reported. Although not designed to distinguish philosophies other than social model, early results suggest that the SMPS may also be used to classify other program philosophies.

Work and identity in substance abuse recovery

Reduction in length of stay due to managed care has forced medical model treatment to focus on detoxification and "medically necessary" services at the expense of "wraparound" social services addressing employment, housing, and family problems. Lower staff and infrastructure costs enable social model programs to offer more (nonmedical) services and a longer stay at comparatively lower cost. Among the services they provide are vocational rehabilitation and job-search training, with the view that participants are better off if re-entry is mediated by sober social networks, stable environments, and employment. This paper demonstrates that employment training/job search activities are integrated into social model programs, and offers qualitative evidence of how staff and advanced residents teach the value of work. Longitudinal quantitative data collected at the same time suggest the focus of social model on employment does make a difference in posttreatment functioning: 1-year follow-up Addiction Severity Index (ASI) scores show decreases in employment problems among social model clients, along with comparable improvement on other composite scores of the ASI.

Demystifying the Betty Ford Clinic: An Immersion Experience

1. The purpose of the Betty Ford Clinic (BFC) Professional in Residence (PIR) Inpatient Program is to increase participants' understanding and awareness of chemical dependency and its treatment. 2. Current alcoholism treatment is a combination of medical, psychosocial, psychological, and spiritual modalities interacting in a framework designed to help the individual achieve and sustain sobriety (Collins, 1993); all of these treatment components are evident in the BFC Model. 3. Double-blind studies are not conducted at the BFC for ethical reasons, which are one of the many difficulties inherent in the use of conventional control designs for assessing the treatment effectiveness of residential drug abuse programs (De Leon, Inciardi, & Martin, 1995).

Policy-relevant program evaluation in a national substance abuse treatment system

This article discusses recent trends in public and private substance abuse services and offers suggestions on how the evaluation of such services can inform clinical practice and policy making. This analysis focuses particularly on the Department of Veterans Affairs (VA), which operates the largest substance abuse treatment system in the United States. In recent years, there has been an erosion of services for substance abuse outside the VA. In contrast, due to increased funding from the U.S. Congress, the VA significantly expanded substance abuse treatment from 1990 to 1994. However, efforts to "reinvent" and downsize government initiated a reversal of this growth trend in 1994, and VA services may shrink further as the system becomes more decentralized and adopts managed care strategies from the private sector. Drawing from the VA Program Evaluation and Resource Center's (PERC) experience of evaluating the VA system and working with federal policy makers, this article presents examples and suggestions for making evaluations of substance abuse treatment systems more useful in policy discussions and in day-to-day clinical practice.

Alcoholism treatment outcome studies, 1980-1992: methodological characteristics and quality

We examine the methodological characteristics and provision of study information in 339 alcoholism treatment outcome studies reported between 1980 and 1992. We consider factors in four methodological domains: sampling and description of patients, specification of treatments, outcome variable assessment and follow-up, and treatment effect estimates; we also consider the methodological quality of the studies. Although methodological quality has improved over time, there remains room for improvement. Of special concern is the low statistical power of many studies. Multiple treatment group studies had an average .54 probability of detecting a treatment effect of medium size.

Recovering substance abuse staff members' beliefs about addiction

This study of 329 substance abuse treatment staff assessed how recovery status, in combination with other variables, influences beliefs about the causes and treatment of substance abuse. About 15% (n = 47) of participants were "in recovery" from substance abuse problems; these staff members were not significantly different than nonrecovering staff members on education, age, race/ethnicity, years of clinical experience, or amount of client contact. When examined in a multiple regression equation that also included age, education, and treatment program goals and activities, staff members' recovery status was not associated with endorsement of disease and psychosocial models of substance abuse. However, being in recovery was associated with endorsing an eclectic approach to substance abuse treatment. The importance of recognizing the diversity of beliefs about substance abuse among recovering staff and of acknowledging that multiple influences affect all staff members viewpoints on treatment is discussed.

Enhancing substance abuse treatment evaluations: examining mediators and moderators of treatment effects

This article considers ways in which the basic, comparative approach to evaluating treatment for substance abuse is sometimes enhanced. The general strategy has been to make treatment evaluation projects explanatory by embedding them in a theoretical framework. Using either a theory of the treatment process or of patient-treatment matching guide, the typical approaches for enhancing comparative treatment evaluations are to identify either mediators or moderators of treatment effects. In addition to addressing the basic question of "Does the treatment work or not work?" one can also ask in more explanatory evaluations: "How or why does the treatment work or not work?" and/or "For whom do treatments work or not work?" Variations of these questions that can be addressed in treatment process and patient-treatment interaction effect analyses are discussed. Particular attention is given to explaining (identifying mediators of) patient-treatment interaction effects. Some advantages of making treatment evaluations more explanatory are discussed.

Characteristics and outcomes of three models of community residential care for abuse patients

Three models of transitional residential community care for substance abuse patients are defined on the basis of the differential provision of health and treatment services: a psychosocial model, a supportive rehabilitation model, and an intensive treatment model. Facilities that provided a high level of on-site health and treatment services were categorized as following an intensive treatment model; these facilities had the strongest emphasis on medical, dual diagnosis, and family treatment orientations. These facilities also had clearer policies and provided their residents more opportunities to participate in setting policies; however, staff were not more accepting of patient impairment or problem behavior. Patients in facilities with intensive treatment programs obtained more outpatient mental health after care. In each of the three types of facilities, a longer length of care was associated with a lower readmission rate; patients who dropped out of psychosocial model facilities had especially high readmission rates. Overall, the findings identify substantial variations among community residential facilities for substance abuse patients, but show relatively little matching of patients' needs with facility services and programs.

Inpatient treatment for substance abuse patients with psychiatric disorders: a national study of determinants of readmission

This study examined the patient case mix and program determinants of 6-month readmission rates and early treatment dropout for 7,711 VA inpatients with both substance abuse and major psychiatric disorders treated in one of 104 substance abuse programs. Patients were treated in one of three types of inpatient programs: explicitly designed dual diagnosis specialty programs, substance abuse programs with a dual diagnosis psychotherapy group or standard substance abuse programs. Dual diagnosis specialty programs differed from regular substance abuse programs in that they had a more severe case mix, a higher 180-day readmission rate, greater dual diagnosis treatment orientation, used more psychotropic medication, had longer lengths of stay, had greater tolerance of relapse and medication noncompliance, and a higher rate of psychiatric aftercare in the 30 days after discharged. Programs with less severe case mix, longer intended and actual length of stay, lower 7-day dropout rates, greater tolerance of problem behavior, 12-step groups, and higher immediate postdischarge utilization of outpatient mental health treatment lower 180-day readmission rates. Programs with less severe patient case mix, more use of psychotropic medications but less of methadone and antabuse, less varied and diverse treatment activities, and low use of patient-led groups had lower dropout rates.