Douglas L. Polcin

Factors associated with coercion in entering treatment for alcohol problems

Although the importance of coercion in entry to treatment for alcohol problems is recognized, few studies have focused on different types and levels of coercion among heterogeneous groups of clients entering treatment agencies. This paper describes demographic and problem characteristics associated with various sources and levels of coercion. More than 40% (n = 377) of individuals entering a representative sample of a countys HMO, public, and private indemnity-based non-DUI alcohol treatment services (n = 927) indicated they received an ultimatum to enter treatment from at least one person. The most common source of an ultimatum to enter treatment was from family members (n = 222), followed by the legal system (n = 78), and healthcare professionals (n = 55). Respondents experiencing pressure to enter treatment reported that ultimatums from more than one source were common. Individuals entering treatment who were most likely to report being coerced were white, young adults (age 18-39), and married or living with a partner. When controlling for demographic characteristics and problem severity, family problem severity and legal problem severity predicted having received an ultimatum to enter treatment. Alcohol and drug problem severity were not related to receiving a treatment ultimatum.

DRUG AND ALCOHOL OFFENDERS COERCED INTO TREATMENT: A REVIEW OF MODALITIES AND SUGGESTIONS FOR RESEARCH ON SOCIAL MODEL PROGRAMS

Outcome studies on drug and alcohol offenders coerced into treatment by the criminal justice system were reviewed. Positive outcomes were found for therapeutic community, methadone maintenance, and unspecified residential and outpatient programs. No outcome studies were found for court-mandated clients coerced into social model recovery programs. When developing studies, researchers should consider how clients perceive legal mandates and whether they are receiving pressures to enter treatment from other sources, such as family members, employers, friends or the welfare system. Use of the Social Model Philosophy Scale (SMPS) is suggested to correlate program characteristics and processes with outcome.

A Clean and Sober Place to Live: Philosophy, Structure, and Purported Therapeutic Factors in Sober Living Houses

Abstract The call for evidence-based practices (EBPs) in addiction treatment is nearly universal. It is a noteworthy movement in the field because treatment innovations have not always been implemented in community programs. However, other types of community-based services that may be essential to sustained recovery have received less attention. This article suggests that sober living houses (SLHs) are a good example of services that have been neglected in the addiction literature that might help individuals who need an alcohol-and drug-free living environment to succeed in their recovery. It begins with an overview of the history and philosophy of this modality and then describes our five-year longitudinal study titled, “An Analysis of Sober Living Houses.” Particular attention is paid to the structure and philosophy of SLHs and purported therapeutic factors. It ends with the presentation of baseline data describing the residents who enter SLHs and six-month outcomes on 130 residents.

Sober living houses for alcohol and drug dependence: 18-month outcomes.

OBJECTIVE A major challenge facing many individuals attempting to abstain from substances is finding a stable living environment that supports sustained recovery. Sober living houses (SLHs) are alcohol- and drug-free living environments that support abstinence by emphasizing involvement in 12-step groups and social support for recovery. Among a number of advantages, they are financially self-sustaining and residents can stay as long as they wish. Although SLHs can be used as housing referrals after inpatient treatment, while clients attend outpatient treatment, after incarceration, or as an alternative to treatment, they have been understudied and underutilized. METHOD To describe outcomes of SLH residents, we interviewed 245 individuals within 1week of entering SLHs and at 6-, 12-, and 18-month follow-up. Eighty-nine percent completed at least one follow-up interview. Outcomes included the Addiction Severity Index (ASI), Brief Symptom Inventory (BSI), and measures of alcohol and drug use. Covariates included demographic characteristics, 12-step involvement, and substance use in the social network. RESULTS Regardless of referral source, improvements were noted on ASI scales (alcohol, drug, and employment), psychiatric severity on the BSI, arrests, and alcohol and drug use. Substance use in the social network predicted nearly all outcome measures. Involvement in 12-step groups predicted fewer arrests and lower alcohol and drug use. CONCLUSION Residents of SLHs made improvements in a variety of areas. Additional studies should use randomized designs to establish causal effects of SLHs. Results support the importance of key components of the recovery model used by SLHs: (a) involvement in 12-step groups and (b) developing social support systems with fewer alcohol and drug users.

Rethinking Confrontation in Alcohol and Drug Treatment: Consideration of the Clinical Context

The role of confrontation in the treatment of substance misuse problems is widely debated in the field. Historically, confrontation of denial has been important in treatment, particularly in residential programs. However, confrontation has also been criticized as counterproductive. Miller et al. colleagues have found that confrontation from treatment professionals is correlated with poor outcome. This paper reviews the literature supporting and criticizing confrontation. It is suggested that confrontation is not a monolithic concept. Rather, it is contingent upon clinical contextual factors that current research has not addressed, such as the treatment setting, treatment philosophy, client characteristics, the clients view about their relationship with confronter, the extent to which the client views the confrontation as legitimate, the clients perception of the confronters motivation, and the level of emotional intensity involved in the confrontive exchange. Confrontation from multiple sources requires more focus, including confrontation from treatment peers, family members, the workplace, the legal system, social welfare workers, and medical professionals.

Sober living houses: potential roles in substance abuse services and suggestions for research.

‘Sober living houses’ are alcohol- and drug-free residences for individuals attempting to establish or maintain sobriety. They offer no formal treatment services but do provide social support and an abstinent living environment. ‘Sober living houses’ have been used as aftercare placements for clients completing residential treatment, places for clients to live while attending outpatient treatment, or as stand-alone approaches for substance misuse problems. This article identifies areas of research needing attention and suggests that ‘sober living houses’ have the potential to play a stronger role in the continuum of substance misuse services.

Psychiatric Severity and Spirituality, Helping, and Participation in Alcoholics Anonymous During Recovery

Although helping others is a critical part of Alcoholics Anonymous (AA) and many treatment programs, measures for assessing helping and describing its relationship with sobriety are lacking. A sample of 200 subjects completed a Helper Therapy Scale including three subscales: Recovery Helping (alpha = 0.78), Life Helping (alpha = 0.62), and Community Helping (alpha = 0.60). A previous analysis using structural equation modeling found that length of sobriety predicted measures of spirituality, helping, and AA participation. The analysis reported here examined whether psychiatric severity was associated with these variables. Results indicated significant relationships between psychiatric severity and measures of spirituality (Self Transcendence, Forgiveness, Positive Coping, and Negative Coping) and AA Achievement (defined as completing the 12 steps and serving as a sponsor). However, no relationships were found between psychiatric severity and length of sobriety, the three Helper Therapy subscales, or AA involvement. The findings suggest that individuals with higher psychiatric severity may need assistance from their peers or professional service providers to develop a spiritual life, serve as a sponsor for others, or complete the steps of AA.

A Model for Sober Housing during Outpatient Treatment

Abstract Finding a living environment that supports recovery is a major challenge for many clients attending outpatient treatment. Yet it is important because family, friends, and roommates who encourage substance use or discourage recovery can undermine the progress made in treatment. Destructive living environments are most problematic for clients who have limited incomes and reside in urban areas where housing markets are tight. Individuals who are homeless face constant threats to their sobriety and often lack the stability necessary to attend treatment consistently. Options Recovery Services is an outpatient program in Berkeley, California that uses sober living houses (SLHs) to provide an alcohol- and drugfree living environment to clients while they attend the outpatient program. This article describes the structure and processes of the houses along with six month outcome data on 46 residents. Improvements were seen in the number of months using substances, maximum number of days of substance use per month, arrests, and employment. Seventy six percent of the residents remained in the house at least five months and 39% reported being employed at some point during the past 30 days. Outpatient programs should consider establishing SLHs for clients who lack a living environment supportive of sobriety.

Eighteen-month outcomes for clients receiving combined outpatient treatment and sober living houses

One of the most frequent and frustrating challenges facing clients in outpatient treatment is finding a living environment that is free of alcohol and drugs, and supportive of recovery. Sober Living Houses (SLHs) have been suggested as one potential solution. Among other advantages, SLHs are financially self-sustaining and residents can remain there as long as they wish, provided they comply with house rules and expectations. This study examined 18-month outcomes for 55 individuals receiving outpatient treatment combined with residence in a SLH. Repeated measures analyses comparing 6-month time periods showed significant improvement on measures of alcohol and drug use, arrests, and days worked. The Addiction Severity Index (ASI) showed significant improvement on legal and employment scales. On ASI alcohol and drug scales, individuals entered SLHs with very low severity that was maintained at 18 months. Involvement in 12-step groups was associated with reductions in alcohol and drug use.

What Did We Learn from Our Study on Sober Living Houses and Where Do We Go from Here

Abstract Lack of a stable, alcohol- and drug-free living environment can b e a serious obstacle to sustained abstinence. Destructive living environments can derail recovery for even highly motivated individuals. Sober living houses (SLHs) are alcohol- and drug-free living environments for individuals attempting to abstain from alcohol and other drugs. They are not licensed or funded by state or local governments and the residents themselves pay for costs. The philosophy of recovery emphasizes 12- Step group attendance and peer support. We studied 300 individuals entering two different types of SLHs over an 18-month period. This article summarizes our published findings documenting resident improvement on measures of alcohol and drug use, employment, arrests, and psychiatric symptoms. Involvement in 12-Step groups and characteristics of the social network were strong predictors of outcome, reaffirming the importance of social and environmental factors in recovery. This article adds to our previous reports by providing a discussion of implications for treatment and criminal justice systems. We also describe the next steps in our research on SLHs, which will include: (1) an attempt to improve outcomes for residents referred from the criminal justice system and (2) a depiction of how attitudes of stakeholder groups create a community context that can facilitate and hinder the legitimacy of SLHs as a recovery modality.