Kirk M. Broome

Effects of readiness for drug abuse treatment on client retention and assessment of process.

AIMS This study examined client motivation as a predictor of retention and therapeutic engagement across the major types of treatment settings represented in the third national drug abuse treatment outcome study (DATOS) conducted in the United States. DESIGN Sequential admissions during 1991-93 to 37 programs provided representative samples of community-based treatment populations. Based on this naturalistic non-experimental evaluation design, hierarchical linear model (HLM) analysis for nested data was used to control for systematic variations in retention rates and client attributes among programs within modalities. SETTING The data were collected from long-term residential (LTR), outpatient methadone (OMT) and outpatient drug-free (ODF) programs located in 11 large cities. PARTICIPANTS A total of 2265 clients in 18 LTR, 981 clients in 13 OMT and 1791 clients in 16 ODF programs were studied. MEASUREMENTS Pre-treatment variables included problem recognition and treatment readiness (two stages of motivation), socio-demographic indicators, drug use history and dependence, criminality, co-morbid psychiatric diagnosis and previous treatment. Retention and engagement (based on ratings of client and counselor relationships) served as outcome criteria. FINDINGS Pre-treatment motivation was related to retention in all three modalities, and the treatment readiness scale was the strongest predictor in LTR and OMT. Higher treatment readiness also was significantly related to early therapeutic engagement in each modality. CONCLUSIONS Indicators of intrinsic motivation--especially readiness for treatment--were not only significant predictors of engagement and retention, but were more important than socio-demographic, drug use and other background variables. Improved assessments and planning of interventions that focus on stages of readiness for change and recovery should help improve treatment systems.

Retention and patient engagement models for different treatment modalities in DATOS.

A model to explain treatment retention in terms of process components--therapeutic involvement and session attributes for the 1st month--and patient background factors were tested in long-term residential (LTR), outpatient drug free (ODF), and outpatient methadone (OMT) treatments. The data was collected in the national Drug Abuse Treatment Outcome Studies (DATOS), and included 1362 patients in LTR, 866 in ODF, and 981 in OMT programs. Structural equation models showed there were positive reciprocal effects between therapeutic involvement and session attributes in all three modalities, and these variables had direct positive effects on treatment retention. Motivation at intake was a strong determinant of therapeutic involvement. Other patient background factors were significantly related to retention, including pretreatment depression, alcohol dependence, legal pressure, and frequency of cocaine use.

Measuring patient attributes and engagement in treatment

Brief but comprehensive instruments measuring patient motivation, psychosocial functioning, treatment process, social network support, and services received are needed for monitoring drug abuse treatment delivery and patient progress. Combining this information across patients within a program also provides useful indicators about institutional composition and functioning. Consequently, the same assessment tools can be used to identify areas where treatment protocols need to be changed, and to monitor improvements following such changes. The Texas Christian University (TCU) Client Evaluation of Self and Treatment (CEST)(1) is a 144-item self-rating instrument that includes 16 scales measuring patient functioning and treatment perceptions. Psychometric properties (including reliability and construct validity) of the scales are examined in this article, based on patient samples drawn from 87 programs that participated in a series of staff training workshops. Acceptable reliabilities (.70 or above) were generally reported, and construct validity was also demonstrated (although the confirmatory factor analyses suggested some item pools could represent more than one factor). Prediction analyses were conducted using selected scales from each measurement domain to illustrate their sensitivity to treatment program contexts.

Legal Pressure and Treatment Retention in a National Sample of Long-Term Residential Programs:

This study examined the association between legal pressure and treatment retention in a national sample of 2,605 clients admitted to 18 long-term residential facilities that participated in the Drug Abuse Treatment Outcome Study (DATOS). Hierarchical linear models were used to assess the relationship of background factors and legal pressure with treatment participation for 90 days or longer. Two thirds of the sample entered residential treatment with moderate to high pressure from legal authorities, and they were significantly more likely than the low-pressure clients to stay 90 days or more. Moreover, the difference in retention between moderate-to-high-and low-pressure clients was even greater in programs with proportionally larger caseloads under legal surveillance. The criminal justice system (CJS) can influence treatment participation and retention, and it appears essential for the CJS and treatment programs to maintain an open and constructive relationship to maximize their potential combined impact.

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.

Recovery from opioid addiction in DATOS

Patient attributions for their own long-term recovery were obtained in a 5-year followup of 432 admissions to 18 outpatient methadone treatment programs. Subjects were classified into two groups - recovering and non-recovering-strictly defined and based on both biological and self-report measures of no opioid or cocaine use, less than daily use of alcohol, and no arrests or illegal activity during the year prior to interview. The 28% who were in recovery at Year 5 reported that they had relied primarily upon personal motivation, treatment experiences, religion/spirituality, family, and their job/career. Particular value was placed on the support from family and close friends, indicating the importance of stronger efforts to develop social networks for support of drug-free functioning, especially among patients who lack these resources or need them strengthened. More information is available on the Internet at www.ibr.tcu.edu.

Legal Pressure, Treatment Readiness, and Engagement in Long-Term Residential Programs

Abstract Clients are less likely to drop out of residential drug treatment programs prematurely when they are either internally motivated (i.e., having a high level of treatment readiness) or externally pressured by the legal system to enter, participate, and remain in treatment. However, little is known about the combined impact these factors have on treatment engagement and retention. This study focused on a national sample of 2,194 clients admitted to 18 long-term residential facilities. Although there was no significant interaction effect, findings indicated that clients with higher levels of treatment readiness at intake stayed in treatment at least 90 days, regardless of legal pressure. Likewise, those under legal pressure (defined by legal status and supervisory pressures) remained in treatment longer, regardless of treatment readiness. However, motivational readiness for treatment accounted for the greatest improvements in retention and, unlike legal pressure, was related to indicators of therapeutic engagement.

Engagement Models for Adolescents in DATOS-A:

Based on the importance of during-treatment activities for improving outcomes, relationships between patient background, treatment readiness, and therapeutic engagement were examined in a national sample of adolescents admitted to 20 treatment programs representing three modalities. Patients with higher readiness for treatment at intake subsequently became more therapeutically involved, replicating previous findings on relationships between motivation and engagement in adult samples. One of the most influential background factors associated with higher treatment readiness was patient relationships with family and friends. Interventions that focus on treatment readiness appear to be appropriate strategies for improving treatment engagement.

Drug treatment process indicators for probationers and prediction of recidivism

Research has shown that substance abuse treatment is associated with reduced criminal activity as well as reduced drug use. An increasingly important aspect of treatment evaluation, however, is understanding more about the therapeutic process involved. Based on a sample of 279 probationers assigned to residential treatment for drug use problems, the purpose of this study is to examine several elements of treatment process and how they influence recidivism. Rearrest rate during a 2-year follow-up study period was 36%, and survival analysis showed it was directly related to poorer during-treatment ratings by probationers of self-esteem, counselor competence, and peer support from others in the treatment program. These were better predictor measures than background and demographic characteristics generally used in other studies, suggesting the role of therapeutic engagement in the recovery process.

Peer, family, and motivational influences on drug treatment process and recidivism for probationers.

Treatment efforts appear to be effective in reducing crime among drug using individuals, but components of the treatment process associated with client improvement need to be identified. Furthermore, these elements of treatment may play an intermediate role in the connection between client background characteristics and later criminal activity. The current study examines a structural equation model including client perceptions of their drug related problems, peer deviance, and family dysfunction as influences upon the formation of therapeutic relationships during treatment and rearrests following treatment. Results showed therapeutic relationships were positively associated with recognition of drug related problems and negatively related to rearrest. Peer deviance also was positively related to rearrest.