Client predictors of treatment retention and completion in a program for homeless veterans

Homeless people: a review of personality disorders

Personality disorders in homeless people pose a challenge to the medical community and society, requiring specialized approaches for these super-difficult patients. The prevalence of personality disorders is higher in homeless populations than in the general population. However, there is a knowledge gap regarding personality disorders among people experiencing homelessness, and the implications of this lack of recognition are substantial. This paper provides a brief narrative review of personality disorders among homeless individuals. The primary importance and specificity of these disorders in this population remain unexplored. We searched PubMed and Web of Science databases in February and November 2023 using the keywords 'homeless' and 'personality disorder', and selected fifty-eight studies to be included in this literature review. The main themes of the results were personality disorders in homeless individuals and comorbid psychiatric disorders; risk factors and other psychological and behavioral data; clinical and intervention outcomes; and challenges linked to assessment, treatment, and intervention. The homeless population experiences significant diagnostic variability and the diagnosis of personality disorders is still evolving, contributing to difficulties in diagnosis, assessment, and treatment. A future challenge is to raise clinical awareness and optimize research knowledge, assessment, and intervention in personality disorders among homeless individuals with comorbid psychiatric disorders.

The Role of Personality Functioning on Early Drop out in Outpatient Substance Misuse Treatment

Treatment initiation is a major factor contributing to positive outcomes, but the supporting literature remains limited. It is difficult to draw conclusions regarding predictors of dropout, and there is a need to target clients' major early attrition vulnerabilities. Despite empirically validated models for assessing personality, little is known about its role in the treatment process. Studies that have been conducted in this area have focused mainly on stable personality traits and provide conflicting evidence. Aims: The aim of this study is to examine to what extent service users' personality functioning are potential determinants of early drop out. Methodology: A cross-sectional multi-site design examined the therapy process in a naturalistic setting in 5 outpatient preparation treatment centers with 210 service users. The current study adopts a contemporary dimensional-based framework, similar to the Alternative Model of Personality Disorder of the DSM-V and examines the role of characteristic adaptations (SIPP-118) on early drop out (CEST-Intake). Findings: From the broad spectrum of personality traits, only Depression remained significant predictor of drop out. Higher dysfunctional levels in Social Concordance [OR] = 1.85, Wald =19.87, p =.002, 95% CI [1.1, 1.9] as well as the facets Aggression Regulation, Respect and Purposefulness were also predictors of early drop out, while Treatment Readiness and Desire for Help accounted for a significant amount of variance. Conclusions: These findings extend our knowledge of the predictive role of characteristic adaptations in treatment and suggest it may be important to assess these individual differences early on and to design personalized-informed interventions.

Examining the Relationship of Personality Functioning and Treatment Completion in Substance Misuse Treatment

Background:

Treatment retention is a major factor contributing to favourable outcome in the treatment of substance misuse, but the literature remains very limited. Despite evidence of the association of personality with drug use experimentation and relapse, surprisingly little is known about its role in the treatment process. Clients’ personality functioning as measured by malleable and context sensitive characteristic adaptations in treatment are of concern.

Aims:

This study examines whether, and to what extent, personality functioning contributes to or hinders treatment completion. This paper examined the extent to which service users’ characteristic adaptations may be potential determinants of treatment completion.

Methodology:

A longitudinal multi-site design was utilised, examining the therapy process in a naturalistic setting in five inpatient treatment units. The study examined whether service users’ characteristic adaptations (SIPP-118) predict completion, while controlling psychosocial, motivational and treatment engagement indicators involving n = 340 participants from 5 inpatient centres. Multivariate regression analyses were applied to examine the predictive role of characteristic adaptations on treatment completion.

Results:

Findings indicated that certain dysfunctional characteristic adaptations emerged as strong predictors of treatment completion. Dysfunctional levels on Self-control and Social concordance were significant predictors of drop out from treatment. Individuals with low capacity to tolerate, use and control one’s own emotions and impulses were almost three times more likely to drop-out compared to those without [OR] = 2.73, Wald = 6.09, P = .014, 95% CI [1.2, 6.0]. Individuals with dysfunctional levels on the ability to value someone’s identity, withhold aggressive impulses towards others and work together with others were 2.21 more times more likely to complete treatment [OR] = 2.21, Wald = 4.12, P = .042, 95% CI [1.0, 4.7]. The analysis at the facet level provided additional insight. Individuals with higher adaptive levels on Effortful Control were 46% more times likely to complete treatment than the group [OR] = 4.67, Wald = 10.231, P = .001, 95% CI [1.81, 12.04], 47% more likely on Aggression regulation [OR] = 4.76, Wald = 16.68, P < .001, 95% CI [2.1, 10.3], and 26% more likely on Stable self-image [OR] = 2.62, Wald = 6.75, P < .009, 95% CI [0.9, 3.0].

Conclusions:

These findings extend our knowledge of the predictive role of characteristic adaptations in treatment completion and highlight the clinical utility of capturing these individual differences early on. Delineating the role of characteristic adaptations in treatment may provide the basis for enhancing treatment effectiveness through individualized interventions that are scientifically driven and may open new avenues for the scientific enquiry of personality and treatment.

Mantram Repetition With Homeless Women: A Pilot Study

Women and families are the fastest growing segment of the homeless population. Negative attitudes of nurses toward homeless women are a major barrier to homeless women seeking health care. This cross-sectional, mixed-methods pilot study, conducted primarily by nurses, tested the Mantram Repetition Program for the first time with 29 homeless women. The Mantram Repetition Program is a spiritually based skills training that teaches mantram (sacred word) repetition as a cost-effective, personalized, portable, and focused strategy for reducing stress and improving well-being. For the cross-sectional, pretest-posttest design portion of the study, the hypothesis that at least half of the homeless women would repeat their mantram at least once a day was supported with 88% of the women repeating their mantram 1 week later. The qualitative portion of this study using phenomenology explored the women's thoughts on mantram week 2. Themes of mantram repetition, mantram benefits, and being cared for emerged. This groundbreaking, interventional, mixed-methods pilot study fills a gap in interventional homeless research.

Treatment Engagement: Female Survivors of Intimate Partner Violence in Treatment for PTSD and Alcohol Use Disorder

OBJECTIVE

Treatment engagement rates are low for individuals with comorbid posttraumatic stress disorder (PTSD) and alcohol use disorders across available interventions and treatment modalities. A better understanding of who does and does not engage in treatment can help improve retention, completion, and subsequent treatment outcomes.

METHODS

Forty female survivors of intimate partner violence with PTSD and alcohol use disorder participated in a randomized controlled trial comparing twenty-five 90-minute sessions of either modified Seeking Safety or Facilitated Twelve-Step in a community-based outpatient clinic. This study examined differences in demographics and pre-treatment PTSD symptoms and alcohol use between participants who engaged in treatment (attended ≥ 6 sessions, n = 18) and those who dropped out (n = 22).

RESULTS

There were no significant differences in PTSD or alcohol use disorder symptoms between treatment conditions. Women who engaged in therapy versus those who did not were significantly older (M = 46.2, SD = 9.14 vs. M = 38.95, SD = 10.49, respectively; p =.027), and had fewer dependents (M =.17, SD =.38, range = 0-1 vs. M =.95, SD = 1.66, range = 1-7, respectively; p =.046). Greater avoidance/numbing PTSD symptoms (OR = 1.13, p =.028, 95% CI [1.02-1.25]) and more years of heavy drinking (OR = 1.04, p =.03, 95% CI [1.00-1.07]) were also significantly associated with treatment engagement.

CONCLUSIONS

This study replicates previous findings suggesting a need for additional retention strategies for younger women with dependents in comorbid PTSD and alcohol use disorder treatment. This is an analysis of data collected as part of a clinical trial registered as NCT00607412, at www.clinicaltrials.gov.

Personality disorders and retention in a therapeutic community for substance dependence

Although therapeutic community (TC) treatment is a promising intervention for substance use disorders, a primary obstacle to successful treatment is premature attrition. Because of their prevalence within substance use treatment facilities, personality disorder (PD) diagnoses have been examined as predictors of treatment completion. Prior research on TC outcomes has focused almost exclusively on antisocial personality disorder (ASPD), and the results have been mixed. This study extends previous research by examining the impact of the 10 Axis II PDs on early (first 30 days) attrition as well as overall time to dropout in a 9-month residential TC. Survival analyses indicated that borderline was the only PD negatively related to overall program retention. In contrast, ASPD, as well as histrionic PD, were related to very early attrition, but not to overall program retention. Early assessment and identification of at-risk individuals may improve treatment retention and outcome for TC treatment.

The influence of co-occurring axis I disorders on treatment utilization and outcome in homeless patients with substance use disorders

The current study examined the relationship between co-occurring substance use and Axis I psychiatric disorders and treatment utilization and outcome among homeless individuals (N=365) who participated in an episode of intensive outpatient substance use treatment. Compared to patients without a co-occurring diagnosis, homeless patients with a diagnosis of major depressive disorder or PTSD participated in more substance use treatment. Diagnostic status did not predict 12-month alcohol or drug treatment outcome. Substance use treatment programs appear to successfully engage homeless individuals with major depressive disorder and PTSD in treatment. Such individuals appear to achieve similar benefits from standard substance use treatment as do homeless individuals without such disorders.

Adherence to Scheduled Sessions in a Randomized Field Trial of Case Management: The Criminal Justice-Drug Abuse Treatment Studies Transitional Case Management Study

The Transitional Case Management (TCM) study, one of the projects of the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative, was a multi-site randomized test of whether a strengths-based case management intervention provided during an inmate's transition from incarceration to the community increases participation in community substance abuse treatment, enhances access to needed social services, and improves drug use and crime outcomes. As in many intervention studies, TCM experienced a relatively large percentage of treatment-group participants who attended few or no scheduled sessions. The paper discusses issues with regard to participation in community case management sessions, examines patterns of session attendance among TCM participants, and analyzes client and case manager characteristics that are associated with number of sessions attended and with patterns of attendance. The average number of sessions (out of 12) attended was 5.7. Few client or case manager characteristics were found to be significantly related to session attendance. Clinical and research implications of the findings and of adherence in case management generally are discussed.

Clinical and demographic factors associated with homelessness and incarceration among VA patients with bipolar disorder

OBJECTIVES

We assessed the association between homelessness and incarceration in Veterans Affairs patients with bipolar disorder.

METHODS

We used logistic regression to model each participant's risk of incarceration or homelessness after we controlled for known risk factors.

RESULTS

Of 435 participants, 12% reported recent homelessness (within the past month), and 55% reported lifetime homelessness. Recent and lifetime incarceration rates were 2% and 55%, respectively. In multivariate models, current medication adherence (based on a 5-point scale) was independently associated with a lower risk of lifetime homelessness (odds ratio [OR] = 0.80 per point, range 0-4; 95% confidence interval [CI] = 0.66, 0.96), and lifetime incarceration increased the risk of lifetime homelessness (OR = 4.4; 95% CI = 2.8, 6.9). Recent homelessness was associated with recent incarceration (OR = 26.4; 95% CI = 5.2, 133.4). Lifetime incarceration was associated with current substance use (OR = 2.6; 95% CI = 2.7, 6.7) after control for lifetime homelessness (OR = 4.2; 95% CI = 2.7, 6.7).

CONCLUSIONS

Recent and lifetime incarceration and homelessness were strongly associated with each other. Potentially avoidable or treatable correlates included current medication nonadherence and substance use. Programs that better coordinate psychiatric and drug treatment with housing programs may reduce the cycle of incarceration, homelessness, and treatment disruption within this vulnerable patient population.

Client retention in residential drug treatment for Latinos

Client drop out from treatment is of great concern to the substance abuse field. Completion rates across modalities vary from low to moderate, not ideal since length of stay has been positively and consistently associated with better client outcomes. The study explored whether client characteristics shown to be related to retention were associated with treatment completion and treatment duration for a sample of 164 Latino substance users who entered a culturally focused residential program. In-person client interviews were conducted within a week of program admission. Logistic regression analysis was used to examine research questions. Clients most likely to drop out had self-reported co-occurring psychiatric diagnoses; they were 81% less likely to complete the program, suggesting that clients with mental health problems have a more difficult time remaining in residential treatment. Clients using drugs in the three months prior to entry were three and a half times more likely to be in the shorter stay group, and clients who lived in institutions prior to program entry were three times more likely to be in the longer-stay group. Factors contributing to drop out for this Latino sample were similar to those identified in the literature for non-Latino samples. Methods for addressing the needs of clients with co-occurring disorders are discussed.

Individual and program predictors of attrition from VA substance use treatment

The study investigated patient- and program-level variables associated with attrition from intensive outpatient (IOP) substance use treatment in a national VA sample. National databases were used to identify a recent cohort of veterans receiving intensive IOP substance use treatment. Attrition was defined as receiving less than five visits of IOP treatment. Patient-level variables examined included age, gender, race, and psychiatric and medical comorbidities. Program-level variables examined included the number of hours of treatment offered, the percentage of patients living on-campus, and extent of staff cuts in the past year. Twenty-seven percent of veterans left treatment early. Being older, female, and having a psychotic disorder was associated with attrition. Program-level factors associated with attrition were the number of hours the program offered treatment, in that more treatment offered was associated with higher attrition. Focus on individual and program level factors associated with attrition is crucial to retaining individuals in treatment.