ARE POST-TREATMENT DIFFERENCES A FUNCTION OF PRE-TREATMENT

CHARACTERISTICS IN NON-COMPLETERS, COMPLETERS, AND GRADUATES

OF THE HOMELESS VETERANS REHABILITATION PROGRAM?

A Dissertation

Presented to the Faculty of

Pacific Graduate School of Psychology

Palo Alto, California

In Partial Fulfillment of the

Requirements for the Degree of

Doctor of Philosophy in Psychology

Lawrence Ferber, Ph.D

September 16, 2006

 ARE POST-TREATMENT DIFFERENCES A FUNCTION OF PRE-TREATMENT
CHARACTERISTICS IN NON-COMPLETERS, COMPLETERS, AND GRADUATES
OF THE HOMELESS VETERANS REHABILITATION PROGRAM?

Lawrence Ferber

Pacific Graduate School of Psychology, 2006

The purpose of this study is to examine pre-treatment characteristics such as

demographics (i.e., race, age, marital status and ethnicity), employment status, level of

education, legal/criminal history, co-morbidity, number of medical issues, number of

psychiatric hospitalizations, number of drug and alcohol treatment episodes, addiction

severity, Global Assessment of Functioning Scores (GAF), number of treatment

completions, and age of onset upon admission in relation to program

completion/graduation in the Homeless Veterans Rehabilitation Program (HVRP). In

conducting this study we hope to obtain an accurate estimate of long-term predictor

variables of program success rates. Two pre-treatment characteristics evidenced

significant results. They were Global Assessment of Functioning Scores and How Long

Individuals had had drug and alcohol problems (alcohol severity). Conclusions drawn

were both yes and no regarding the researched question that this study addressed, which
was, do pre-treatment characteristics play a significant role in the function of post-

treatment outcomes?
© Copyright 2006

by

Lawrence Ferber

All Rights Reserved

ii
 ARE POST-TREATMENT DIFFERENCES A FUNCTION OF PRE-TREATMENT
CHARACTERISTICS IN NON-COMPLETERS, COMPLETERS, AND GRADUATES
OF THE HOMELESS VETERANS REHABILITATION PROGRAM?

This dissertation by Lawrence Ferber directed and approved by the candidate’s

committee has been accepted and approved by the Faculty of Pacific Graduate School of

Psychology in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY

IN PSYCHOLOGY

May 15, 2006

William Froming, Ph. D
Vice-President for Academic Affairs

Dissertation Committee:

____________________________________
Matthew Cordova, Ph.D.
Chair

____________________________________
Keith Harris, Ph.D.
Committee Member

____________________________________
Thomas Burling, Ph.D.
Committee Member

iii
 DEDICATION

Many special people have provided help and encouragement throughout a number

of stages of this research project. Appreciation is expressed to Matthew Cordova, Ph.D,

Keith Harris, Ph.D., and Thomas Burling, Ph.D. for their careful academic guidance and

warm concern during the dissertation process. This dissertation became an important

learning experience with the responsive involvement of all of the committee members.

Their insight, questions and challenges were critical to the development of my research

skills.

Without the participation of 132 men and 4 women, this research project could

have not been implemented. Gratitude is expressed to each of the research subjects for

their interest in providing information to expand the body of knowledge regarding pre-

treatment characteristics and how they relate to post-treatment outcomes.

Finally, deep gratitude is expressed to the friends and family who have sustained

me emotionally during this time, and especially to Andrea, who always saw the glass half

full and when times got tough, always managed to keep a smile on my face.

iv
 TABLE OF CONTENTS

Focus...............................................................................................................................4

Epidemiology .................................................................................................................5

Substance Abuse Treatment Outcomes...........................................................................6

Treatment Duration.......................................................................................................11

After Care as a Way of Extending Treatment Duration................................................14

Treatment Completion..................................................................................................16

Predictors of Treatment Retention, Completion, and Outcome....................................18

Demographics ..........................................................................................................19

Criminal Behavior and Legal Issues........................................................................22

Psychiatric Co-Morbidity.........................................................................................24

Severity of Drug Use................................................................................................26

Previous Treatment Episodes...................................................................................26

Drug Careers/ Number of Treatments.....................................................................27

Age of Onset............................................................................................................28

Therapeutic Communities and Data on Their Effectiveness ........................................29

Strengths...................................................................................................................31

Weaknesses .............................................................................................................31

HVRP Follow-up Study................................................................................................32

Proposed Study.............................................................................................................33

Participants....................................................................................................................36

Procedures.....................................................................................................................36

Measures ......................................................................................................................37

v
 Depressive Symptoms..............................................................................................37

Analyses .......................................................................................................................38

Historical Data ............................................................................................................41

Hypothesis #1: Beck Depression Inventory Scores......................................................45

Hypothesis #2: Global Assessment of Functioning Scores (GAF)...............................45

Hypothesis #3: Number of Previous Psychiatric Stays.................................................47

Hypothesis #4: Number of Past Substance Abuse Treatments.....................................47

Hypothesis #5: Number of Jobs Within the Past 10 Years...........................................47

Hypothesis #6: Higher Levels of Education.................................................................47

Hypothesis #7: Age of Onset........................................................................................48

Hypothesis #8: Ethnicity...............................................................................................48

Hypothesis #9: Jail Time...............................................................................................48

Hypothesis #10: Marital Status.....................................................................................48

Hypothesis #11: Age.....................................................................................................49

Hypothesis #12: Medical Issues....................................................................................49

Hypothesis #13: Drug and Alcohol Problems Total Time............................................49

Significant Findings .....................................................................................................53

Non-Significant Findings..............................................................................................55

Age, Gender and Education.....................................................................................55

Employment Status..................................................................................................56

Marital Status...........................................................................................................57

Criminality and Legal Involvement.........................................................................58

Psychiatric Hospitalization History..........................................................................59

vi
 Age of Onset.............................................................................................................60

Depression and Treatment Outcome........................................................................61

Number of Substance Abuse Treatment Episodes ..................................................61

Limitations....................................................................................................................63

Clinical Implications.....................................................................................................64

Future Directions...........................................................................................................65

Summary.......................................................................................................................66

vii
 LIST OF TABLES

Table Page

1 Sociodemographic Characteristics (N=136)..............................................................39

2 Descriptive Statistics for Primary Study Variables....................................................43

3 Testing Primary Hypotheses (N=136)........................................................................51

viii
 LIST OF FIGURES

Figure Page

1 Figure 1. Global Assessment of Functioning (GAF) - graduate status......................46

2 Figure 240. How long with drug and alcohol problems-graduate status...................50

ix
 1

CHAPTER

I. INTRODUCTION

“Quitting smoking is easy. I’ve done it hundreds of times.”

-Mark Twain.

Early patient attrition has presented a challenge for providers of substance abuse

treatment (Klein, Menza, Arfken, & Schuster, 2002). While there is evidence for the

efficacy of substance abuse treatment programs (Gerstein & Harwood, 1990; Brewer,

Catalano, Haggety, Gainey, & Fleming, 1998), rates of patient drop-out have remained

high, ranging from 25% to 80% (Klein, et al., 2002). Patient retention is an important

goal for substance abuse intervention in that patients who drop out of treatment are more

likely to relapse to drug/alcohol use and other high-risk behaviors than those who

complete treatment (Magura, Nwakeze, & Demsky, 1998; Brewer et al, 1998; Klein et

al., 2002). Identifying predictors of patient retention in substance abuse treatment could

inform clinical interventions that would lead to improved retention, and possibly better

long-term outcomes (Benda, 2001).

The Homeless Veterans Rehabilitation Program (HVRP) at the VA Palo Alto

Health Care System was the first domiciliary in the nation to combine the components of

a Therapeutic Community (TC) and evidence-based Cognitive Behavioral (CB)

techniques. Studies have demonstrated the efficacy of this program (e.g., Burling,

Seidner, Salvo, & Marshall, 1994). Data were recently collected from 225 previous

patients measuring rates of drug or alcohol use, unemployment, and homelessness after

completion/discharge from the program (Harris, Schauder, Wain, Ferber, Malcus, and

Burling, 2005). Analyses compared the data for three separate groups: non-completers,
 2

completers, and graduates. Non-completer were defined as residents that failed to

complete his or her 180-day inpatient treatment stay (e.g., discharged early, did not

complete all four treatment phases, failed to secure housing or employment before

discharging). Completers were defined as residents that met all of the 180-day inpatient

program requirements but did not fulfill the 13-week outpatient requirement necessary to

graduate. Graduates were defined as residents that completed both the 180-day inpatient

treatment program and the additional 13 weeks of outpatient aftercare. “Survival time”

was defined by the time until any break in abstinence, employment, and/or housing

status.

Survival analyses suggested that non-completers fared most poorly, with the

lowest rates of abstinence, housing, and employment, as well as the shortest survival time

of the three groups. Graduates had significantly higher rates of abstinence, housing, and

employment than completers, and also had significantly longer survival times on all three

outcome measures (abstinence, housing and employment). A composite measure

assessing “total failure” (i.e., relapsed, homeless, and unemployed) revealed significant

differences between all three groups: Non-completers (29%) were significantly more

likely than completers (18%), who were significantly more likely than graduates (3%) to

experience total failure. Thus, HVRP program completion/graduation appears to play an

important role in long-term success rates (Harris et al., 2003). Specifically, these data

suggest that completing both the 180-day program and the 13-week aftercare requirement

(i.e., graduating) predicts significantly better post-treatment outcomes in terms of

substance use, housing, and employment.

 3

Given the apparent link between program retention and long-term outcome

demonstrated in this recent study, it is important to identify factors associated with

program completion. It is possible that the results of this recent study were accounted for

by pre-treatment differences across the 3 groups (non-completers, completers, graduates)

with regard to characteristics such as demographics (gender, race, and age), employment

status, level of education, marital status, global assessment of functioning score,

legal/criminal history, psychiatric co-morbidity (e.g., depression), addiction severity,

number of treatment episodes, number of psychiatric hospitalizations, number of medical

issues, age of onset and treatment completion status (Brewer et al., 1998). In other words,

individuals with the best outcomes may simply be those who began treatment with the

fewest barriers.

There have been numerous qualitative reviews of patient variables related to

outcome for substance use treatment (McClellan, 1983; Hawkins & Catalano, 1985;

Westermeyer, 1989; Anglin & Hser, 1990; Catalano, Wells, Hawkins, Miller, & Brewer,

1990-1991). Length of stay has repeatedly been found to be one of the best predictors of

long-term outcome (Bleiberg, Devlin, Croan, & Briscoe, 1994; De Leon, 1991; De

Leon& Schwartz, 1984; Savage & Simpson, 1981). Research is needed on variables that

predict “length of stay,” as well as variables with unique predictive power above and

beyond length of stay in predicting long-term outcomes.

Identifying pre-treatment patient characteristics associated with retention in

substance abuse treatment could facilitate refinement of clinical interventions that could

remove barriers to treatment completion and lead to better long-term outcomes An

example of this is the issue of co-morbidity. Substance abuse and depression are among
 4

the most prevalent and costly disorders confronting the health care system, and they are

highly comorbid with substance abuse (Nunes, & Levin, 2004). The co-occurrence of

disorders leads to greater overall severity and worse health-related outcomes, including

an increased risk of suicide (Nunes & Levin, 2004). Researchers have developed a wide

range of initiatives in order to improve screening and diagnosis of depressive and drug or

alcohol use disorders in primary medical care settings where they are known to

commonly present, as well as in mental health or addiction treatment programs (Nunes &

Levin, 2004). Less than a decade ago, the treatment of depression among substance

dependent individuals was discouraged by most therapists (Nunes et al., 2004). Although

depression is under-recognized and under-treated in substance abuse treatment (Nunes et

al., 2004), there is an increased acceptance of the importance of treating both disorders

simultaneously. If depression is found to be negatively linked to retention in substance

abuse treatment, it would suggest the necessity of integrative approaches that target mood

disturbance early in treatment.

Focus

The primary purpose of the present study is to identify pre-treatment

characteristics associated with treatment retention in a long-term domiciliary-based

therapeutic community, the Homeless Veterans Rehabilitation Program (HVRP), in the

VA Palo Alto Health Care System. The following literature review examines studies of

the epidemiology of substance abuse, substance abuse treatment outcomes, the role

length of stay plays in treatment outcome, the role of aftercare, and the factors that

influence length of stay and long-term outcomes.

 5

CHAPTER

II. LITERATURE REVIEW

Epidemiology

Substance use disorders are among the most prevalent conditions confronting the

health care system (Nunes & Levin, 2004). In the year 2000, approximately 14.5 million

Americans, 6.5% of the population, were classified with dependence on or abuse of

alcohol and/or illegal drugs (SAMHSA, 2000). Alcohol use disorders were estimated in

approximately 12 million people, whereas drug use disorders were estimated in

approximately 2.5 million people.

Drug and alcohol abuse has been called the country’s number one health issue

with regard to economic, health, and societal impact (Murray & Lopez, 1997). In 1992,

the economic costs to U.S. society of drug abuse and alcohol abuse were estimated at

97.7 and 148 billion dollars, respectively (Swan, 1998). Substance-related disorders are

responsible for approximately 120,000 deaths each year, with tobacco accounting for an

additional 500,000 deaths per year (SAMHSA, 2000). In the year 2000 within the

Veterans Administration Health Care System alone, about 20% of all inpatients carried a

substance-related disorder diagnosis; drug and alcohol related disorders were responsible

for about 1.2 million days of in-patient medical care (SAMHSA, 2000).

Over a quarter of a trillion dollars are spent each year in preventable costs

regarding health care, additional police enforcement and automobile crashes (Fleming &

Barry, 1992). In 1992, the costs of crime that were attributed to substance abuse were

estimated at 58.7 billion dollars (Swan, 1998). Drug abuse was implicated in the cost
 6

analysis as the cause of 25 to 30% of all income-generating crime, such as burglary and

robbery (Swan, 1998). Enormous costs to society were attributed to lost income for

incarcerated drug criminals and lost legitimate income and criminal justice system costs

due to drug abuse, including drug traffic control expenditures, totaling 17.4 billion dollars

in 1992 (Swan, 1998). Given the pervasive and costly nature of substance use disorders,

development of effective treatment modalities is paramount. The following section

reviews the literature on substance abuse treatment efficacy.

Substance Abuse Treatment Outcomes

Little is known about the effectiveness of the substance and alcohol treatment

approaches most commonly available to patients, their families, and referring agencies

(Jaycox, Marshall, & Morral, 2002). A number of studies investigating the effectiveness

of community-based treatments for individuals with substance-related disorders use

observational designs that compare drug use and other problem behaviors in the period

preceding treatment admission to some point after treatment discharge. These studies,

which include the Drug Abuse Reporting Program (Sells & Simpson, 1979), the

Treatment Outcomes Perspective Study (Hubbard, Cavanaugh, Craddock, & Rachal,

1985), the National Treatment Improvement Evaluation Study (Gerstein, & Johnson,

1999), and the Drug Abuse Treatment Outcomes Study (Hser et al., 1999), tend to

confirm that drug-related problems and other problem behaviors diminish after treatment

admission (Jaycox et al., 2002).

The Drug Abuse Reporting Program (DARP) study was based on data from

44,000 patients that had been admitted to 52 community-based substance abuse treatment

programs between 1969 and 1972 (Hiller, Knight, Devereux, & Hathcoat, 1996). This
 7

study found that treatment worked for individuals with opiate-related substance use

disorders, as measured by significant reductions in crime and drug use, and that treatment

could be provided in community-based programs for patients not under civil commitment

(Hiller et al., 1996). Additionally, the DARP study found that the length of time spent in

treatment was also related to outcomes, that trained lay staff could effectively treat

patients, and that methadone maintenance, therapeutic community, and drug free

outpatient programs had similar positive outcomes (Hiller et al., 1996). The DARP study

developed the methodology that would be used in many future treatment assessment

studies and also showed that follow-up studies were feasible (Simpson & Curry, 1997).

The Treatment Outcome Prospective Study (TOPS) at the Research Triangle

Institute (RTI) examined 11,750 patients that had been admitted to 41 treatment programs

between 1979 and 1981 (Hubbard, Cavanaugh, Craddock, & Rachal, 1985). TOPS has

been considered one of the most persuasive illustrations of the effectiveness of treatment

(Hubbard et al., 1985). TOPS found that treatment reduced heroin and cocaine use, that

this reduction was maintained for a minimum of at least two years post-treatment, and

that patients with legal involvement stayed in treatment slightly longer (Hubbard et al.,

1985). Additionally, TOPS demonstrated that treatment was effective in reducing drug

abuse up to five years after a single treatment episode (Hiller et al., 1996). TOPS also

reported that by serving as an alternative to incarceration, treatment can be especially

beneficial for drug abusers identified in jails or prisons, and it can play a central role in

helping to fight against the spread of immunodeficiency syndrome (AIDS) by reducing

the intravenous use of heroin and other drugs (Hiller et al., 1996). Finally, findings from

TOPS suggested that legal pressure tended to keep individuals in treatment for longer
 8

periods of time and that this coercion did not interfere with treatment goals (Hubbard et

al., 1985). The potential reduction of criminal behavior has been one of the most

compelling reasons in favor of drug treatment: “three to five years after leaving

treatment, the proportion of patients who were involved in predatory criminal activity

was one-third to one-half of the pre-treatment proportion” (Hubbard et al., 1985, p.22).

This reduction in criminal activity had important cost effectiveness implications—for

every dollar spent on treatment there was a $7 savings due to reduced criminal activity

(Hubbard et al., 1985).

The Drug Abuse Treatment Outcome Studies (DATOS) project was a

collaborative national research program designed to evaluate the effectiveness of

community-based drug treatment in the United States (Simpson & Curry, 1997). Between

1991 and 1993, a total of 96 treatment programs in 11 cities, and a total of 10,010

patients were chosen to reflect typical community-based treatment services available to

the public (Simpson et al., 1997). DATOS used repeated measures methodology, putting

together detailed levels of measurement and multiple comparison groups. Four treatment

modalities were represented: (a) Outpatient Methadone Treatment (OMT), (b) Long-

Term Residential (LTR), (c) Outpatient Drug-Free (ODF), and (d) Short-Term Inpatient

(STI) (Anglin et al., 1997). DATOS demonstrated that post-treatment drug use was

reduced for all modalities, although treatment repeaters had worse substance use and

criminal outcomes than those in treatment for the first time (Anglin et al., 1997).

Project MATCH was an 8-year multi-site investigation of how patients respond to

different treatment approaches designed to assist them in recovering form alcohol related

disorders. Project MATCH was designed to test the hypotheses that matching patients to
 9

different treatment approaches would improve treatment outcomes (Project MATCH

Research Group, 1993). Two independent but parallel matching studies were conducted,

one with patients recruited from outpatient settings, the other with patients receiving

aftercare treatment following inpatient care (Project MATCH Research Group, 1993).

Patients were randomly assigned to Twelve-Step Facilitation, Cognitive-Behavioral

Coping Skills, or Motivational Enhancement Therapy. Participants were followed at 3-

month intervals for 1 year following completion of the 12-week treatment period and

were evaluated for changes in drinking patterns, functional status/quality of life, and

treatment services utilization (Project MATCH Research Group, 1993).

Project MATCH is the largest trial of psychotherapies that has ever been

undertaken and involves 1726 patients, 25 senior investigators, 80 clinicians, and many

more research assistants and support staff, at over 30 participating institutions and

treatment facilities (Gordis & Fuller, 1999). The sample was generally representative of

patients treated for alcoholism in the United States (Gordis et al., 1999). Outcome

evaluations were conducted at 3-month intervals during the first 15 months of follow-up

at all sites. In addition, 39-month follow-ups were completed at the five outpatient sites

(Project MATCH Research Group, 1993).

Results were that patients in all three treatment conditions showed major

improvement not only on drinking measures, but in many other areas of life functioning

as well. These areas included functional status, quality of life, and treatment services

utilization (Gordis et al., 1999). Patients who received a period of residential or day-

hospital treatment immediately before being enrolled in MATCH were able to sustain
 10

longer periods of abstinent time than those treated on an outpatient basis only (Gordis et

al., 1999).

Making firm conclusions about treatment outcome can be somewhat difficult for a

number of reasons (Heather, Batey, Saunders, & Wodak, 1989). First, several studies

suggest that conventional treatment is no better than minimal contact (Heather et al.,

1989). Second, given the multiple areas of health and lifestyle that are affected by

substance abuse, it has been problematic for researchers to agree on a single or

comprehensive set of program success indicators (Henggeler, Pickrell, & Brondino,

1996). When comparing reviews and studies of alcohol treatment, the complexity of

etiology, treatment, settings, and patients must also be kept in mind (Marlowe, 2004). For

example, treatment programs may focus on one modality or may be multimodal,

including medically-based, psychotherapeutically-based, and self-help-based

interventions (Marlowe, 2004). The fact that treatment settings differ with regard to

outpatient versus inpatient status, staffing patterns, and the kinds of populations who

choose or are chosen for the setting, adds to the complexity of observational studies

comparing treatment programs (Marlowe, 2004).

To address this problem, some have emphasized the importance of using classical

experimental designs, including selection of a homogeneous sample, use of control

groups, randomization, and multimodal assessment (including physical, emotional, and

behavioral outcomes) to evaluate treatment efficacy (Kaminer, 2001; Marlow, 1989).

While such small scale, single-modality trials, or “efficacy trials,” can determine the

therapeutic factors that contribute to the observed outcomes (Kaminer, 2001), only

“effectiveness trials,” real-world clinical trials, have the flexibility to incorporate

 11

interventions from various treatment approaches as necessary to meet the patient’s needs

—such trials may have greater generalizability and speak to the relative benefits of

community-based programs (Kaminer, 2001).

Treatment Duration

The positive association of treatment duration and treatment completion with

continued abstinence has been well studied (Anglin et al., 1997; Brewer et al., 1998; De

Leon, 1997; Goethe, Weinstein, Sterling, & Lundy, 1998; Orlando et al., 2003; Sears,

Davis, Guydish, 2002; Stark, 1992). In 1991, De Leon discussed length of stay as being

“the most consistent predictor variable of successful outcome” (De Leon, 1991). When

discussing longitudinal associations, treatment duration pertains to the amount or length

of time in treatment from admission to discharge (Brewer et al., 1998). Treatment

completion refers to completing treatment as opposed to being discharged for other

reasons. Across a large number of studies, treatment duration and completion have been

negatively related to continued use whether the associations were measured concurrently

or longitudinally, indicating that individuals that remained in treatment longer and

completed treatment were less likely to continue using then those who left treatment

earlier and did not complete treatment (Brewer, et al., 1998). Such findings have been

replicated in DARP, DATOS, and TOPS (Simpson, 1983). Length of stay represents a

focal indicator of treatment effectiveness and can be regarded as a convenient index of

several patient, therapeutic, and environmental factors (Simpson, 1997).

McCusker et al. (1997) randomized patients with drug and alcohol problems

between two residential treatment facilities and found evidence for greater efficacy of a

program of longer duration. Better outcomes were found in the 6-month versus the 3-
 12

month program with regard to the time from admission to first drug use, and with regard

to severity of addiction-related problems at the 18-month follow-up assessment

(McCusker, 1997). In the “longest stay stratum,” the group of patients in the 12-month

program had a longer time from admission to first drug use, lower Addiction Severity

Index scores (ASI), fewer legal problems, and a more favorable employment status than

those patients who had a lesser length of stay (McCusker et al., 1997).

Simpson et al. (1999) examined post-treatment outcomes in a national study of

1605 cocaine dependent patients. Patients with the most severe problems were more

likely to enter long-term residential programs. Better outcomes were reported by those

treated 90 days or longer (Simpson et al., 1999).

Pelissier et al. (2004) evaluated the effectiveness of a three-phase residential

facility operated by the Federal Bureau of Prisons. The program is based on the bio-

psycho-social model of treatment that recognizes the complex interrelationships between

psychological, biological, and social variables (Pelissier et al, 2004). The inmates

typically receive nine months of treatment in a drug abuse treatment unit, a transitional

period, up to a year, in the general population with relapse prevention strategy planning

and review of treatment techniques, and a community transition period following release

into a community halfway house. The treatment is comprised of a standardized

curriculum of modules including screening and assessment, orientation of treatment,

criminal lifestyle confrontation, cognitive skills building, relapse prevention,

interpersonal skill building techniques, wellness and transitional programming (Pelissier

et al., 2004). Offenders who completed the residential drug abuse treatment program, and

had been released to the community for three years under supervision were less likely to
 13

be re-arrested or revoked compared to inmates who did not receive such treatment

(Pelissier et al., 2004). Length of time in treatment and completion of treatment were

critical factors to success in the program (Pelissier, et al., 2004).

Magura et al. (1998), investigated the effects of pre-treatment variables on patient

retention with 1206 substance dependent individuals and found length of stay in

treatment to have an effect consistent with a longer time in treatment and was related to

improved outcomes (Magura, Nwakeze, & Demsky, 1998). Additionally, the authors

found shorter time in treatment to be significantly correlated to treatment non-completion

(Magura, et al., 1998). Similarly, a study of dually diagnosed women by Brown,

Melchior, and Huba (1999) found that longer lengths of stay were associated with

positive outcomes such as abstinence, having a safe place to live, and plans for

employment, school, or training (Timko & Moos, 2002).

Despite some controversy about the long-term efficacy of residential placements,

national studies involving large treatment samples, such as DATOS, have demonstrated

that residential treatment for substance abuse is more effective that outpatient modalities

(Anglin, et al., 1997; Jainchill, Hawke, De Leon, & Yagelka, 2000), particularly for

patients with high severity substance abuse disorders (Moos, Finney, & Cronkite, 2000;

Simpson et al., 1999). Moos et al. (1994) found that patients who had longer episodes of

Community Residential Facility (CRF) care had lower readmission rates than both

community patients and patients who had shorter episodes of CRF care (Moos et al.,

1994). These findings held for individuals with substance abuse with psychiatric

disorders as well as for those with only substance-related disorders (Moos et al., 1994).
 14

Therapeutic community outcome studies have consistently shown length of stay

and program completion to be central predictors of treatment outcome (Anglin et al.,

1997; Benda, 2001; Chou, Hser, & Anglin, 1997; Ciraulo, Piechniczek-Buzek, & Iscan,

2003; Moos et al., 2000). Orlando, Chan, and Morral (2003) found that length of stay and

treatment completion were associated with reduced substance abuse problem severity and

increased abstinence rates in a sample of adolescent outpatient and residential treatment

program participants. Messina and colleagues (2000) found that treatment completion

was the only significant predictor of a positive urinalysis at treatment follow-up. Simpson

(1984) reported that treatment durations of 3 months or more are associated with better

outcomes. Other studies suggest that the risk of alcohol relapse is substantially lower for

those patients who remain in treatment 1-6 months (50% as likely) or greater than 6

months (33% as likely), compared to those who leave treatment within one week (Anglin

et al., 1997; Caplehorn, Lumley, & Irwig, 1998; Klein et al., 2002; Orlando et al., 2003).

After Care as a Way of Extending Treatment Duration

Aftercare, or continuing care, is defined as activities and support provided to the

substance abusing patient following program completion, to help solidify the gains made

while in treatment (Rounds et al., 1999). Aftercare follows discharge, when the patient no

longer requires services at the intensity required during primary treatment. The patient is

able to follow a self-directed plan, which includes minimal contact with a therapist or

counselor. The interaction between the patient and the counselor takes on a monitoring

function. Patients continue to reorient their behavior toward a pro-social, clean, and sober

lifestyle (Rounds et al., 1999). Aftercare can occur in a variety of forms, such as periodic

out-patient relapse prevention, 12-step, and self-help groups (Rounds et al., 1999).
 15

Research has demonstrated that approximately 50% of the variation in post-release

failure in adult populations can be attributed to post-treatment factors such as aftercare

(Rounds et al, 1999). About 66% of all relapses occur within the first 90 days following

treatment (Marlatt & Gordon, 1985), making this period a primary target of aftercare.

Recent research has shown superior outcomes when patients complete all phases

of treatment, including aftercare (Rounds et al., 1999). Alcohol abuse treatment programs

with an aftercare dimension have been shown to be more effective (McKay, Maisto, &

Farrell, 1993) and may be associated with reduced long-term medical costs (Lash, 1998).

Substance abuse patients who attended two or more outpatient mental health visits in the

month after discharge from inpatient care, had lower than expected readmission rates

(Moos, Pettit, & Gruber, 1995). Moos, Pettit, and Gruber (1995) investigated the lengths

of time patients’ remained in a community residential facility (CRF) and participated in

aftercare. They found that the patients with longer periods of aftercare had significantly

lower readmission rates when compared to the patients that were discharged directly to

the community after inpatient treatment (Moos, Pettit, & Gruber, 1995). In a large sample

of participants (N=407) involved in hospital based treatment, Walker et al., (1983) found

that abstinence rates were significantly higher for aftercare completers (70%) compared

to aftercare drop-outs (23%).

Some data suggest that aftercare may increase self efficacy, which in turn may

lead to improved outcomes (Marlatt et al., 1985). Further, aftercare may address co-

occurring issues and facilitate the identification and strengthening of patients’ skills,

interests, and creativity, (McKay, 2001). Aftercare provides patients with the skills to

anticipate, avoid, and/or cope with high risk situations that threaten control and increase
 16

to probability for a lapse or relapse (Ito, Donovan, & Hall, 1988). A recent study

investigated possible predictors of participation in aftercare and 12-month return-to-

custody (RTC), with 4,155 inmates that chose to participate in prison-based therapeutic

community treatment in California (Burdon, Messina, & Prendergast, 2004). Increased

time spent in prison-based treatment predicted increased participation in aftercare and

decreased 12-month RTC (Burdon et al., 2004).

Prison-based substance abuse treatment (much like a therapeutic community type

setting) is effective if combined with aftercare and leads to major reductions in

recidivism (Wexler, Melnick, Lowe, & Peters, 1999). Wexler et al. (1999) conducted a

study involving 478 prisoners at a state prison near San Diego, California. A found that

after three years, only 27% of the prisoners involved in the prison’s drug treatment

program with aftercare returned to prison, compared to a recidivism rate of 75% for those

not involved in the treatment program (Wexler et al., 1999). In sum, after care appears to

be a vital component of effective substance abuse treatment and is associated with

improved long-term outcomes.

Treatment Completion

Regardless of intended treatment duration, treatment retention is an important

factor impacting long-term outcome. Non-completion of alcohol abuse treatment due to

drop-out or discharge is the fate of approximately 20-50% of patients in inpatient

treatment programs (Rabinowitz & Marjefsky, 1998). Thus, understanding links between

treatment retention and long-term outcomes, as well as predictors or retention, is an

important focus of research.

 17

Treatment retention has been associated with better long-term outcomes in

substance abuse patients. In DATOS (Anglin et al., 1997; Caplehorn et al., 1998), in the

year following residential or non-residential rehabilitation counseling, of patients who

had been using heroin or cocaine on a weekly basis before treatment and who completed

at least 3 months of treatment, 80-90% were abstinent. For patients who left treatment

earlier than 3 months, only 50-60% were abstinent (Anglin et al., 1997). In 1999, Grella,

Hser, Joshi, and Anglin investigated the relationships among pretreatment patient

characteristics, treatment retention, and treatment outcomes among younger and older

adults in the DATOS and found a strong positive relationship between treatment retention

and abstinence at follow-up for younger adults. Roberts and Nishimoto (1996) found that

patients who completed treatment were three times more likely to be drug-free a year

later when they were compared with those who dropped out. Success rates (on composite

indices of no drug use and no criminality) in Therapeutic Communities at 2 years post-

treatment are approximately 90%, 50%, and 25%, respectively, for graduates/completers

and drop-outs who remain more than one month and less than 1 year in residential

treatment. Improvement rates over pre-treatment status are approximately 100%, 70%,

and 40% respectively (De Leon, 1994; Simpson, 1992).

Treatment completion has been associated not only with reduced drug and alcohol

use, but with a number of other positive outcomes as well (Finigan, 1996). Finigan

(1996) found that treatment completers had 70% fewer incarcerations in the three-year

period following treatment than non-completers. Treatment completion was also

associated with higher wages, less use of food stamps, fewer open child welfare cases,

reduced utilization of medical services, and lower health care costs (Finigan, 1996).
 18

Predictors of Treatment Retention, Completion, and Outcome

Given the importance of treatment duration and completion, identification of

factors associated with treatment drop-out can serve to facilitate treatment retention and

long-term outcomes (Henggler, Pickrel, Brondino & Crouch, 1996). Risk factors for

treatment drop-out have received research attention (De Leon, 1991, 1997; Grella et al.,

1999), but many of the relevant literature reviews have not used adequately systematic

and quantitative methods (Benda, 2001; Bovasso, 2001; Ciraulo, Piechniczek-Buczek, &

Iscan 2003). As a result, there is some confusion regarding specific risk factors and their

predictive utility (Brewer, Catalano, Haggerty, Hainey, & Flemming, 1998). For

example, some program-based investigations reveal inconsistent and/or weak

relationships between drop-out and demographic factors, drug use characteristics, and

psychosocial adjustment (De Leon, 1991, 1997). Major problems in substance abuse

treatment include patients’ dropping out of treatment or failure to comply with treatment

recommendations. Dropout rates are high, regardless of the type of treatment used.

Because treatment retention and compliance have been consistently linked to better

outcomes, these factors remain important targets with substance abuse treatment (De

Leon, 1991).

One way researchers have tried to identify risk-factors for treatment drop-out has

been to identify variables associated with continued drug use. Brewer, Catalano,

Haggety, Gainey, and Fleming (1998) used meta-analytic techniques to identify risk

factors for continued drug use in patients treated for opiate abuse. They included 69

studies that reported information on the bivariate association between one or more

independent variables and continued use of illicit substances both during and after
 19

treatment. A total of 28 independent variables were identified for which there were at

least two studies with results on the association between the independent variable and

continued substance use (Brewer et al., 1998). The 28 variables were then grouped into

eight basic conceptual categories. In addition to treatment duration/completion,

categories included demographics, employment, drug use history, non-opiate drug use,

physical and mental comorbidity, criminal behavior and legal problems, and psychosocial

variables (Brewer et al., 1998). Data regarding many of these risk factors are presented

next.

Demographics

Relationships between demographic factors and substance abuse treatment

outcomes have received considerable attention. Specifically, gender, ethnicity, age,

employment status, and education have been evaluated as potential predictors of

treatment outcome (Brewer et al., 1998). There is a need for researchers to continue

investigating the association between demographic characteristics and individuals who

abuse substances (Brewer et al., 1998).

Gender. Some studies that have found women to drop out of treatment more often

than men (Anglin et al 1990). Other studies have found men to be at greater risk for

attrition (Chou, Hser, & Anglin, 1998). However, Wexler, Falkin, and Lipton (1990)

found no significant correlation between gender and treatment outcome. Hser, Huang,

Teruya, and Anglin (2003) investigated gender comparisons of drug abuse treatment

outcomes and predictors among a sample of 511 patients that were recruited from drug

and alcohol treatment programs across Los Angeles County. There were no significant

differences by gender in drug and alcohol use at follow-up, but males reported more legal
 20

difficulties than females. Logistic regression analyses revealed that for both men and

women, longer treatment retention was associated with drug abstinence and less criminal

activity at follow-up (Hser, Huang, Teruya, & Anglin, 2003). It is suggested that future

research should continue to address the issue of gender differences among drug and

alcohol users (Maglione, et al, 2000). Just as men and women can respond to different

types of treatment, variations in treatment environments can have different impacts on the

outcome of one gender group (Moos, Finney, & Cronkite, 2000).

Race/Ethnicity. Race/ethnicity has been an inconsistent predictor of treatment

retention and outcome (Ryan, Plant, & O’Malley, 1995). There is some evidence that

Caucasians tend to stay in treatment longer compared to other ethnic groups and that

African-Americans have lower dropout rates than Hispanics (Ryan, Plant, & O’Malley,

1995). In contrast, Kleinman et al. (1992) found that Hispanics were more likely than

African-Americans to exhibit longer-term retention. Some of these inconsistencies in the

literature may very well be due to the different number of treatment methods that were

studied (Maglione et al., 2000).

Age. Age has not consistently predicted program retention or outcome. Maglione

et al. (2000) found that older patients were more likely to remain in treatment than

younger patients. Others have found that patients who enter treatment at an older age

were more likely to have a successful treatment outcome (Farrokh, et al., 1995). Stephens

and Contrell (1998) found that patients less than 30 years of age became re-addicted to

narcotics at much higher rates than patients over 30 years old. However, Babst,

Chambers, and Warner (1971) reported that in a sample of patients in methadone

maintenance, younger patients were more likely to be retained than older ones. Similarly,
 21

Kleinman et al. (1992) found that among cocaine users in out-patient psychotherapy,

long-term retention was associated with being younger.

Employment. Employment has been known to predict retention in treatment as

well as favorable treatment outcomes (McLellan, 1993; Klein et al., 2002). In the Brewer

et al. (1998) meta-analysis, unemployed patients were more likely to continue drug use

behaviors post-treatment than those who were employed. Hartley and Phillips (2001)

reported that pre-treatment employment was associated with more successful treatment

outcome. Knapp et al. (1991) studied 157 opiate addicts admitted to a drug dependence

treatment unit and found that pre-treatment occupational functioning was the strongest

predictor of post-treatment employment success. Higher levels of employment problems

have been associated with poorer outcomes regardless of treatment setting (Condelli &

Hubbard, 1994; Klein et al., 2002; McLellan, 1993). Costello (1975) showed that the

major determinant of outcome variance was patient social stability, defined in this case as

simply whether or not the patient was married an/or employed.

It has been estimated that 70% of patients admitted to substance abuse treatment

are unemployed (Blum et al., 1993). This, in combination with the association between

employment and treatment completion/success, suggests that job training and work

programs for substance abuse patients warrant increased attention (Hartley & Phillips,

2001). Not only does employment contribute to successful outcomes in treatment, it also

plays a critical role in retention and the reduction of the occurrence and severity of

relapse (Gerstein et al., 1999; Platt, 1995). Employment provides the person in recovery

the ability to enhance self-esteem and to build confidence and self-worth by providing the

individual with the opportunity to invest in something at which he can be successful

 22

(Platt, 1995). Additionally, work becomes the primary vehicle for reintegrating the

individual into the community as a productive and contributing member of society. In

other words, it becomes a means for social readjustment (Platt, 1995).

Education. Educational background has been a significant predictor of success in

substance abuse treatment (Hartley & Phillips, 2001). In a study of 157 drug addicts,

Knapp et al. (1991) found graduation from high school and higher verbal IQ to be

associated with favorable outcomes. Furthermore, Rush (1979) found that having been in

either school or an educational training program at the time of admission predicted better

outcomes (Knapp et al., 1991). Patients with higher educational levels may be more

likely to receive treatment (Wu, Hoven, & Fuller, 2003) and may have more support and

structure in place to foster program completion (Hartley & Phillips, 2001).

Criminal Behavior and Legal Issues

The relationship between substance abuse and crime has been documented and

discussed in a number of reports (Roll, Prendergast, Richardson, Burdon, & Ramirez,

2005; Young & Belenko, 2005). It’s clear that people that abuse substances, especially

heavy substance abusers, commit a disproportionate amount of crime (Young & Belenko,

2002). Results from the Arrestee Drug Monitoring (ADAM) Program, which was

operating at a number of central booking facilities in 35 US cities during 1998, reported

that between 43% and 79% of male arrestees and between 33% and 82% of female

arrestees tested positive by urinalysis for at least one drug at the time of their booking

(Young & Belenco, 2002). The Bureau of Justice Statistics (BJS) found that 60.2% of all

convicted jail inmates reported that they were under the influence of drugs and/or alcohol

at the time of their offence and 16.1% reported that they were using both drugs and
 23

alcohol (Young & Belenko, 2002). Additionally, a 1997 survey of prison inmates showed

that 83% reported a history of regular and frequent drug use, 56% reported using drugs in

the month before their arrest, and 53% reported that they were using drugs and/or alcohol

at the time of their offense (Mumola, 1997). Crime is often associated with impoverished,

drug and alcohol using environments (Farrokh, Stephens, Liorens, & Orris, 1995). About

two-thirds of the patients in long-term residential substance abuse treatment, one-half of

the patients in outpatient substance abuse treatment, and one-quarter of the patients in

methadone maintenance treatment are presently awaiting a criminal trial or sentencing,

have been sentenced to community supervision on probation, or were conditionally

released from prison on parole (Craddock, 1997). Sustained abstinence from narcotics is

associated with a 40-75% reduction in crime (Harrell & Roman, 2001). Such data suggest

an important link between criminal behavior and substance abuse.

Several studies have examined the relationship between a number of criminal

behavior/legal variables and continued drug and alcohol use (Brewer et al., 1998;

Johnson et al., 1998). Generally, a history of criminal behavior and legal problems show

positive longitudinal relationships with continued substance abuse (Brewer et al., 1998).

Addicts who have few or no arrests have a higher abstinence rate than those who have

had numerous arrests (Farrokh, et al., 1995). Hoogerman et al. (2001) conducted a study

of 314 patients involved in an intense peer group, cognitive-behavioral treatment setting.

Patients with fewer legal difficulties, and whose parents did not have a history of

difficulty with the law had better outcomes. Messina, Wish, and Nemes (2000) found that

the number of prior arrests at program admission was positively associated with the
 24

number of post-discharge arrests, and that those with more arrests were less likely to be

abstinent and employed at follow-up (Messina, Wish, & Nemes, 2000).

Psychiatric Co-Morbidity

Data suggest that the prevalence of comorbid psychiatric and substance use

disorders is rising (Timko & Moos, 2002) and that dual diagnosis patients have more

severe substance abuse problems and worse health related outcomes (Nunes, & Levin,

2004). In the general population, estimates of the combined prevalence of substance

abuse and depression are about two times higher (odds ratio= 1.9) than would be

expected by chance associations. Rates of co-morbidity are even higher among alcoholics

sampled from patient and institutional samples (Brown & Ramsey, 2000). Alcoholics

without a co-morbid diagnosis have a significantly smaller amount of lifetime hospital

admissions, compared to those with a co-morbid diagnosis (Schade et al. 2003). The co-

occurrence of major depression in substance abuse patients has been known to increase

the risk of suicide (Bovasso, 2001). In sum, evaluation of the impact of co-morbidity on

treatment outcome is an important area of study.

Compton III et al. (2003) investigated the relationship between psychiatric

comorbidity and drug abuse treatment outcome. Baseline depression and anxiety

predicted worse outcomes at follow-up (Compton III, et al, 2003). Others have found that

the more severe the co-morbid psychiatric symptoms, the smaller the improvement after

treatment for alcohol and drug abuse (Schade et al., 2003). Schmitz et al. (2000)

compared 50 depressed cocaine dependent patients with 101 patients who were cocaine

dependent only. Depressed patients reported higher craving for cocaine and lower self-

efficacy to refrain from drug use (Schmitz et al., 2000). Pre-treatment depression and
 25

anxiety are associated with a shorter time to slip and relapse following an episode of

treatment, as well as greater risk to relapse (Brown & Ramsey, 2000). Across several

types of addictive substances, situations involving negative mood states are among the

most frequently cited precipitants of relapse (Brown, & Ramsey, 2000). As demonstrated

by Rounsaville et al. (1987), alcoholics with comorbid psychiatric problems had the

worst outcomes. Timko and Moos (2002) found that dually diagnosed patients who had

more severe symptoms (such as concentration difficulties, sleeping issues, depression,

and anxiety) at intake had poorer outcomes at the 1-year follow-up in the alcohol use,

legal, psychiatric, and family/social domains than did patients with less severe symptoms.

Benda (2001) studied 568 veterans following substance abuse treatment and found the

dually diagnosed patients were 6.67 times more likely to be re-hospitalized for substance

abuse and psychiatric problems.

Research suggests that more treatment is generally beneficial for dually diagnosed

patients (Luke et al., 1999; Moos, Finney, Federman, & Suchinsky, 2002). Alterman,

McLellan, and Shifman (1993) found that dually diagnosed patients who received more

treatment showed more improvement at a 7-month follow-up. Similarly, a study of dually

diagnosed women by Brown, Melchior, and Huba (1999) found that longer lengths of

stay were associated with positive outcomes such as abstinence, having a safe place to

live, and plans for employment, school, or training (Brown et al., 1999). A 1-year follow-

up of dually diagnosed inpatients reported better outcomes for patients who participated

in continuing specialized outpatient mental health care than for those who did not obtain

such care (Brown et al., 1999).

 26

Only recently has research investigated the efficacy of intervention strategies for

the dually diagnosed (Ciraulo, Piechniczek-Buczek, & Iscan, 2003; Bovasso, 2001;

Benda, 2001; Brown & Ramsey, 2000). Adequate treatment of psychiatric co-morbidity

and improvement in social, economic, and family functioning has led to better substance

abuse treatment outcomes (Ciraulo et al., 2003). Nunes and Levin (2004) found that when

anti-depressant medication was effective in treating depression, it also helped to diminish

the quantity of substance use (Nunes & Levin, 2004).

Severity of Drug Use

Chronic and severe drug and alcohol abuse are associated with poorer retention in

treatment and more rapid relapse to substance use following treatment (Rounds-Bryant,

Kristiansen, & Hubbard, 1999). One recent study by Klein, Menza, Arfken, and Schuster

(2002) showed the increase and severity of drug and alcohol related problems to be a

consistent predictor of lower retention and completion rates. Numerous studies have

found a positive relationship between level of drug use, number of different drugs used,

and dropping out of treatment (Kleinman et al., 1992). Maglione, Chao, and Anglin

(2000) found that more severe drug use, as measured by frequency of use and route of

administration, was significantly associated with early drop out rates.

Previous Treatment Episodes

Some individuals are able to sustain long-term positive behavioral changes after a

single treatment intervention, while others require multiple treatment episodes to produce

substantial change over time (Hser, Joshi, Anglin, & Fletcher, 1998). Marlowe (2004)

found that for outpatient cocaine users, prior treatment experience was a significant

positive predictor of treatment retention and for each month spent in treatment, there was
 27

a 2.3% decrease in the probability of early dropout. Participation in formal treatment and

longer time in treatment have been associated with better outcomes (Laudet, Savage, &

Mahmood, 2002). Previous treatment has been found to have positive cumulative effects

(Joe, Simpson, & Broome, 1998). Kedia and Williams (2003) studied 1,350 patients

treated for alcohol or drug abuse in residential, halfway house, or outpatient facilities and

found that previous treatment history was the main significant pre-treatment

characteristic that predicted successful outcomes. In contrast to what might be expected

in light of the above findings, recent research has found that patients with previous

treatment histories were more likely to have more severe substance abuse issues, co-

morbid psychiatric problems, and an overall greater amount of problems in other life

areas than those with no prior treatment experience (Fortuin-Corsi, Kwiatkowski, &

Booth, 2002).

Drug Careers/ Number of Treatments

The Drug Abuse Treatment Outcome Study (DATOS) provided an opportunity to

investigate variations in drug use and treatment use over the “careers” of patients entering

drug abuse treatment in the 1990s (Anglin, Hser, & Grella, 1997). There were several

implications of treatment career concept derived from the interpretation of treatment

effectiveness in DATOS. The analyses suggested that more extensive treatment history

was associated with not only more severe addiction career characteristics but also other

negative behaviors such as engaging in sex work, committing illegal activities, and

having less history of full-time employment (Anglin et al., 1997). Although these

findings suggest that patients in DATOS with extensive histories of prior treatment may

be more dysfunctional in many domains, this should not lead to erroneous conclusions
 28

that treatment was not effective for them (Anglin, et al., 1997). In this context, treatment

outcome evaluations need to be controlled for level of severity of other problems

concomitant with drug use and should assess the effectiveness of different levels of

treatment exposure in helping patients reduce their drug and alcohol use (Anglin et al.,

1997).

Age of Onset

Increased attention has focused on prevention of adolescent substance use

(Johnson et al., 1998). The earlier a child begins the use of alcohol and drugs, the greater

the risk of becoming involved in a wide scope of problematic outcomes such as

aggressive behaviors, failure at school, delinquency, and especially later problem use of

substances (Kaplow, Curran, & Dodge, 2002). Early onset of drug use predicts

subsequent misuse of drugs (Rachal, et al., 1982). Rachal et al. (1982) showed that

misusers of alcohol begin to drink at an earlier age than do social users. The earlier onset

of any type of drug use, the greater the involvement in other drug use, and the greater the

frequency of use (Rachal et al., 1982). Additionally, the earlier the initiation into drug use

also increases the probability of extensive and persistent involvement in the use of more

dangerous drugs, and the probability of involvement in deviant activities such as crime

and the selling of illicit substances (Kandel, Simcha-Fagan, & Davies, 1986). In 1985,

Robbins and Przybeck evidenced that the onset of drug use before age 15 was a

consistent predictor of drug abuse in the samples they studied (Robbins and Przybeck,

1985).

Several recent investigations using event history analysis and regression analysis

have reported that early initiation to substance use remains a highly significant factor for
 29

both the use of other drugs and the experiencing of other drug-related problems (Lynskey

et al., 2003). In a recent study by Lynskey et al., (2003) the results of co-twin control

analyses evidenced that early initiation of cannabis use was associated with significantly

increased risks for other drug use/dependence. Patients who used marijuana before age of

17 years old had a 2.3 to 3.9 fold increase in odds of other drug use and a 1.6 to 6.0 fold

increase in odds of alcohol dependence and other drug abuse/dependence, relative to their

co-twin who had not used marijuana by age 17, regardless of whether or not the pair were

monozygotic (Lynskey et al., 2003).

Patients that have a long history of substance use/addiction and began using

substances at an early age may be slightly more likely to continue to use substances

during as well as after treatment than patients with relatively short histories of substance

abuse and later onsets of substance use (Brewer et al., 1998). A patient’s age at the onset

of his addiction and upon admission to treatment is important in the prediction of relapse

because a younger addicted person is less likely to have stable support networks, such as

those provided by a healthy marriage and adult employment, that could end up helping

the patient remain drug-free (Farrokh et al., 1995). Overall, previous research has found

that age of onset of substance use is not only related to involvement in delinquent

activities but also to success in treatment outcome (Chou, Hser, & Anglin, 1998, Knapp

et al., 1991).

Therapeutic Communities and Data on Their Effectiveness

Of all the strategies used to intervene into the negative behaviors of chronic

substance abusers, the therapeutic community (TC) has proved to be one of the most

effective (De Leon, 1997; Neilsen, & Scarpitti, 1997). TC’s began in the 1960’s as a self-
 30

help alternative to existing drug and alcohol abuse treatment (Messina, Wish, & Nemes,

2000). Even though therapeutic communities (TCs) have been successful in the treatment

of substance abuse for over 30 years, elaboration of the underlying theoretical framework

of the substance abuse treatment model and method is a recent development (De Leon,

1991, 1997).

The therapeutic community is a drug-free treatment model that uses a social

psychological approach to the treatment of drug and alcohol abuse (De Leon, 1994).

Therapeutic communities typically offer a wide range of services, including social,

psychological, educational, medical, legal, and social advocacy (De Leon, 1991, 1994).

Additionally, the TC can be distinguished from other major substance abuse treatment

modalities in two fundamental ways (De Leon, 1994). The first way the TC offers a

methodical treatment approach guided by an explicit outlook on the drug use disorder, the

person, the recovery, and right living (De Leon, 1994). The second objective is that the

primary “therapist” and teacher in the TC is the community itself, which consists of the

social environment, peers, and staff who, as role models of successful personal change,

serve as guides in the recovery process (De Leon, 1994). This makes the community both

the context which change occurs and the process for facilitating change (De Leon, 1994).

The TC views drug and alcohol abuse as a disorder of the whole person. Even though

individuals may differ in their choice of substance, abuse involves some or all of the

areas of functioning (De Leon, 1997). The main goal of the TC is to try to resolve a

number of issues, including a global change in lifestyle reflecting abstinence from illicit

substances, the elimination of antisocial behaviors and activities, increased employability,

and an increase in pro-social attitudes, values, and activities (De Leon, 1991, 1997).
 31

Strengths

The TC has been the treatment of choice for the more severe, antisocial, or

socially disaffiliated substance abuser (De Leon, 1985). This population of patients is in

need of a major lifestyle and identity change and this requires long-term treatment

involvement. There have been a number of previous studies that have confirmed the

effectiveness of modified TC’s regarding special populations of substance abusers such

as those with co-occurring mental illnesses, adolescents, veterans, and inmates in

correctional facilities (Wexler, Falkin, & Lipton, 1990). The TC model has been the best

example of an effective self-help, recovery oriented approach to chemical dependence

(Wexler et al., 1990). When contrasted with conventional medical and mental-health-

oriented strategies, the model underscores the importance of empowering the individual

in the change process, makes use of peer communities, as well as facilitates change (De

Leon, 1994). The TC paradigm stresses and provides the environment for patients to

change lifestyles and identities. Thus, the TC remains the treatment of choice for the

more severe drug user, the homeless person, the antisocial, and socially disaffiliated (De

Leon, 1997).

Weaknesses

However, the TC method is limited in its responsivity to individual differences.

Although the patient is the continual focus of the TC, the structure and process elements

of a peer community as method approach may not be flexible enough to meet the

particular needs of each and every individual (De Leon, 1994). Thus, there may be

tension between the needs of the individuals and the needs of the community. Further,
 32

TC’s may be most appropriate for certain subgroups of substance abusers, notable the

most severe users, and those who appear to be socially deviant.

In summary, the TC has been shown to be a powerful social psychological

alternative to pharmacological treatments of substance abuse and related problems such

as homelessness. The TC is oriented to a “recovery way of lifestyle,” not simply

abstinence or the reduction of symptoms (De Leon, 1994). A “recovery way of lifestyle”

can be seen as the recovering individual modifying particular maladaptive behaviors such

as lying, cheating, and stealing (De Leon, 1994). As with the general treatment outcome

literature, treatment retention in TC’s is thought to be a central predictor of treatment

outcome. However, little is known about factors that impact retention in TC’s.

HVRP Follow-up Study

The HVRP follow-up study in 2003 was designed to evaluate the role of aftercare

in treatment outcomes. Outcomes included drug and alcohol use, housing status, and

employment status since discharge. HVRP has been deemed a National Center of

Excellence and is part of the VA Palo Alto Health Care System.

A survival analysis was used to determine months after discharge until substance

use relapse (i.e., any break in abstinence) homelessness, or unemployment. Subgroup

survival analysis was also conducted, where success rates were compared for program

graduates (180 days inpatient treatment plus approximately 13 weeks outpatient

aftercare), completers (180 days inpatient treatment only), and non-completers (more

than 24 hours, less than 180 days). Results showed that each group differed significantly

on each measure. Non-completers fared most poorly, with the lowest rates of abstinence,

housing, and employment status. Additionally, non-completers had the shortest survival
 33

time of the three groups (non-completers, completers, and graduates). Completers and

graduates also differed significantly on all three measures (abstinence, housing and

employment status), with graduates fairing better in these domains. Finally, a composite

measure assessing “total failure” showed significant differences between all three groups.

Non-completers (29%) were significantly more likely than completers (18%), who were

significantly more likely than graduates (3%) to experience total failure.

While it is apparent that completion/graduation status was strongly associated

with subsequent outcomes, it is unclear whether these differences across the 3 groups are

simply a function of differences in baseline characteristics. It is possible that baseline

characteristics, that in and of themselves have been shown to predict long-term outcomes,

may have been associated with treatment completion status. The results of the HVRP

follow-up study may help to provide a better understanding of the long-term effects of

patient care provided at HVRP, and may help to identify ways to improve HVRP and

eventually other treatment programs.

Proposed Study

In this study, we investigated whether pre-treatment characteristics predict

whether patients would be non-completers, completers, or graduates. In other words, how

important are specific variables that the patient “brings to the table” when entering

treatment to subsequent outcomes. Based on the literature review above, several potential

predictor variables were identified, including: (a) depression, (b) number of years

individuals have had substance abuse problems, (c) number of psychiatric hospital stays,

(d) number of previous substance abuse treatments, (e) number of arrests, (f) amount of

jail time, (g) number of medical problems, (h) age of onset of drug and/or alcohol use, (i)
 34

global indices of functioning (i.e., GAF scores), (j) level of education, (k) marital status,

and (l) age.

Based on previous studies, several hypotheses were generated. It was predicted

that:

1. Graduates and completers would have fewer symptoms of depression (as

measured by the Beck Depression Inventory) at baseline than non-completers, and

graduates would have lower baseline depression scores than completers.

2. Graduates and completers would have higher DSM-IV global assessment of

functioning (GAF) scores at baseline than non-completers.

3. Graduates and completers would have fewer previous psychiatric hospital stays

than non-completers.

4. Graduates and completers would have fewer previous substance abuse treatment

episodes than non-completers, and graduates would have fewer treatment

episodes than completers.

5. Graduates and completers would have had more jobs in the 10 years prior to

entering the treatment program, compared to non-completers and graduates.

6. Graduates and completers would have higher levels of education than non-

completers.

7. Graduates and completers would have later “age of onset” of drug or alcohol

abuse than non-completers.

8. The three groups would not significantly differ in racial/ethnic make-up.

 35

9. Graduates and completers would have fewer prior incarcerations and less jail time

than non-completers, and graduates would have fewer incarcerations and less jail

time than completers.

10. Graduates and completers would be more likely to be married than non-

completers.

11. Graduates and completers would be older than non-completers, and graduates

would be older than completers.

12. Graduates and completers would have fewer medical problems than non-

completers.

13. Graduates and completers would have had drug and alcohol problems for less

time than non-completers.

In conducting this study, we hoped to identify predictors of program retention.

With the recognition of demographic and substance use factors that may serve as

obstacles for individuals preparing to go into treatment, clinicians may begin to target

patients with these characteristics in a pro-active way in order to encourage treatment

initiation as well as raising treatment attendance rates.

 36

CHAPTER

III. METHOD

Participants

Participants in this current study were comprised of 136 new recruits from the

follow-up study. To be eligible, participants had to (a) have been discharged from HVRP

between 2004 and 2005, and (b) be able to read and comprehend the consent form and

questionnaire. Sociodemographic characteristics of the study sample are displayed in

Table 1. Participants were a mean age of 48.2 years, (SD= 6.98, range; 25-62). Ethnic

diversity was as follows: 46.4% African American, 43.4 % Caucasian, 5.6% Hispanic,

and 3.5% Other. The sample was 97% male and 3% female. Many participants were

diagnosed with a comorbid psychiatric disorder and most had previously received

substance abuse treatment.

Procedures

This study used previously collected data, and did not involve any new

participation on the part of the follow-up study participants. All procedures used in this

study were approved by the Institutional Review Boards (IRB) for research with human

subjects at Stanford University and Pacific Graduate School of Psychology. For quality

management purposes the original data were collected at HVRP functions, out-patient

visits back to the program, by telephone interviews and by mail from 136 previous

patients measuring rates of drug and alcohol relapse, unemployment, and homelessness

after either completion or discharge from the program. Participants were invited to

participate in a survey study of how program participants were faring in terms of post-
 37

treatment drug and alcohol relapse rates, unemployment and homelessness. Once written

informed consent was obtained, (See Appendix A), participants completed a brief paper-

and-pencil questionnaire which took approximately 2 to 5 minutes for each participant to

complete. All data to be used in this study were stored in a password-protected clinical

database (Filemaker Pro), from which data were extracted and analyzed. Data were

collected via clinical admission interviews and then were exported to Microsoft Excel

and then to SPSS (Version 10.0) for statistical analyses. The only pencil and paper

measure used was the Beck Depression Inventory-II (BDI).

Measures

Depressive Symptoms

The Beck Depression Inventory-II (BDI) (Beck, Steer, & Garbin, 1988) is a 21-

item self-report inventory measuring characteristic attitudes and symptoms of depression.

Respondents select from 1 to 4 severity options for each symptom and it takes about 10

minutes to complete. It requires a fifth-sixth grade reading age to adequately understand

the questions (Groth-Marnat, 1990). Although there have been some inconsistencies in

recent studies concerning the BDI’s factor structure, the BDI has shown sound

psychometric properties with a variety of normal and psychiatric populations (Beck et al.,

1988). Alpha coefficients range from .84 to .87 for each of the dimensions measured by

the BDI (Beck et al., 1988). Overall, the relevant literature is favorable towards the use of

the BDI with both clinical and non-clinical populations (Beck et al., 1988).
 38

Analyses

All analyses were conducted using the Statistical Package for the Social Sciences

(SPSS, Version 11.0). Comparison of group differences (across non-completers,

completers, and graduates) in BDI scores, GAF scores, previous number of

incarcerations, previous drug and alcohol treatment episodes, previous psychiatric

hospital stays, age, and age of onset were tested using One Way ANOVAs. Post-hoc

analyses on significant findings were conducted using Tukey tests and followed up by

pair-wise comparisons. Group differences in education, employment, race, and marital

status were tested using Chi-square statistical analysis (Klein et al., 2002; Farrokh, 1995).

All statistical tests were two-tailed and alpha level for all analyses was set at .05.
 39

Table 1

Sociodemographic Characteristics (N=136)

Variable Non-completers Completers Graduates n F χ2

Mean Age 48.8 48.5 46.7 136 1.048

Gender .502
Male 47 53 32 132
Female 1 1 2 4
Marital status .733
Married 2 4 2 8
Single 16 17 15 48
Separated 6 4 0 10
Divorced 24 29 17 70
Ethnicity .521
African

American 22 24 16 62
Caucasian 23 27 12 62
Hispanic 3 2 3 8
Other 0 2 2 4

(table continues)
Table 1 (continued)

Variable Non-completers Completers Graduates n F χ2

Religion .729
Catholic 5 8 9 22
Christian 26 31 18 75
Protestant 4 2 3 9
Other 3 1 0 4
None 10 11 5 26
Education .529
< High school 5 5 2 12
High school or 39 38 29 106
 40

GED
AA degree 2 7 3 12
BA/BS degree 1 3 0 4
Graduate work 0 1 1 2
 41

CHAPTER

IV. RESULTS

Historical Data

The sample of this current study was comprised of participants who had a mean

age of 48. 2 (SD=6.98 range: 25-62). Their mean educational status (in grades) was 12.2

(SD=1.72, range: 7-20) which indicated that many of our participants were high school

graduates or had made it to high school before dropping out of school. The mean number

of jobs held for the subjects in the study was 6.3 (SD=5.76, range: 0-50) within the past

10 years. The mean number of years individuals had had a drug and alcohol problem was

16.2 (SD=14.17, range: 0-40). The mean number of medical problems was 4.9 (SD=2.06,

range: 1-11) upon admittance to the program. The mean number of arrests was 7.1

(SD=12.4, range: 0-120). The mean GAF score was 67.2 (SD=6.97, range: 50-83), which

indicates mild levels of symptomatology and some difficulties in social or occupational

functioning. The mean Beck Depression Inventory (BDI) score was 13.4 (SD=8.53,

range: 0-40), which indicates that many of our participants had a BDI score endorsed in

the minimal to moderate diagnostic range of depressive symptoms. The mean number of

psychiatric hospitalizations was .570 (SD=1.90, range: 0-15). This statistic implied that,

although there were residents whom we would consider to have co-morbid issues, for the

most part, many of our residents (non-completers, completers, and graduates) had never

been hospitalized due to a co-morbid condition. The mean months of jail time was 8.7

months (SD=15.1, range: 0-109). The mean age of onset with drugs and/or alcohol was

14.2 years (SD=3.43, range: 4 -21). The mean number of previous substance abuse

programs was 2.1 (SD=2.18 range: 0-15).

 42

The sample consisted of 132 males and 4 females. Regarding the marital status of

our participants, there were 8 people married, 48 people single, 10 people separated, and

70 people divorced. With regard to ethnicity, there were a total of 62 African-Americans,

62 Caucasians, 8 Hispanics, and 4 of other ethnicities. Religious/spiritual make up

consisted of 75 Christians, 22 Catholics, 9 Protestants, 4 Other, and 26 No Affiliation or

None. Descriptive statistics for primary study variables, by outcome group, are shown in

Table 2.
Descriptive Statistics for Primary Study Variables Table 2
43
44
 45

Hypothesis #1: Beck Depression Inventory Scores

We hypothesized that graduates and completers would have fewer symptoms of

depression at baseline than non-completers, and graduates would have lower baseline

depression scores than would completers. However, in analysis of variance (ANOVA)

results, no significant difference was evidenced, F(2, 133) = .133, ns.

Hypothesis #2: Global Assessment of Functioning Scores (GAF)

We hypothesized that graduates and completers would have higher GAF scores

than would non-completers. An ANOVA revealed a significant effect of group on GAF

score, F (2, 133) = 35.6, p < 05. Post hoc multiple comparisons evidenced that non-

completers (M = 61.6, SD = 6.16) had significantly lower GAF mean scores than did

completers (M = 70.2, SD = 4.16) and did graduates (M = 70.3, SD = 6.83). However,

GAF mean scores of completers and graduates were not significantly different.
 46
Global Assessment Functioning

72
70
68
66
64
62
60
58
56
Noncompleters Completers Graduates

Figure 1. Global Assessment of Functioning (GAF) - graduate status.

 47

Hypothesis #3: Number of Previous Psychiatric Stays

We hypothesized that graduates and completers would have fewer previous

psychiatric hospital stays than would non-completers. However, results revealed that

these groups did not differ with regard to number of psychiatric hospital stays, F(12, 135)

= .324, ns.

Hypothesis #4: Number of Past Substance Abuse Treatments

Our hypothesis was that graduates and completers would be more likely to have

had fewer previous substance abuse treatment episodes than would non-completers, and

furthermore, that graduates would be more likely to have had fewer treatment episodes

than completers. However, the three groups did not differ with respect to previous

substance abuse treatment episodes, F(18, 135) = .324, ns.

Hypothesis #5: Number of Jobs Within the Past 10 Years

We hypothesized graduates and completers would have had more jobs in the 10

years prior to entering the treatment program, and that non-completers, and graduates and

completers would be more likely to have been employed at admission than would non-

completers’. Our hypothesis was not supported, F(32, 128) = .023, ns

Hypothesis #6: Higher Levels of Education

We hypothesized graduates and completers would have had higher levels of

education than did non-completers. This was not the case, F(20, 135) =.366, ns.
 48

Hypothesis #7: Age of Onset

We hypothesized that graduates would have had a later age of onset than did

completers and non-completers. Our hypothesis was based on the assumption that the

earlier the initiation of substance abuse, the greater the difficulty of remaining in

treatment. We found no significant differences between the three groups. Our findings

were not significant, F(32, 133) = .509, ns.

Hypothesis #8: Ethnicity

We hypothesized that there would be no differences regarding racial/ethnic

backgrounds. We found this to be the case (see Table 1). There were no significant

differences between the three groups in terms of racial/ethnic background, χ 2 (12, N =

136) = .521, ns.

Hypothesis #9: Jail Time

We hypothesized that graduates and completers would have had fewer prior

incarcerations than non-completers, and graduates would have fewer incarcerations than

did completers. We found no significant differences regarding the number of times

individuals had been arrested, and the actual time served, as measured by the mean

number of months. Neither ANOVA analysis results for number of arrests,

F(2,127)=.240, ns, nor time served, F(2, 132)= .080, ns, were significant.

Hypothesis #10: Marital Status

We hypothesized that graduates’ and completers’ would be more likely to be

married than non-completers’. This was not the case. Thus, our hypothesis was not

supported, χ 2 (18, N = 136) = .733, ns.

 49

Hypothesis #11: Age

We hypothesized that graduates and completers would be older than non-

completers would be. Using an ANOVA we did not find evidence of significant

differences between the groups, F(60, 136)= .103, ns.

Hypothesis #12: Medical Issues

We hypothesized graduates’ and completers’ to have had fewer medical problems

than non-completers’ upon admission to the program. We did not find this to be the case,

F(18, 135) = .485, ns.

Hypothesis #13: Drug and Alcohol Problems Total Time

We hypothesized that graduates and completers would have had less total time

with drug and alcohol problems. An ANOVA revealed a significant effect of group on

drug and alcohol problems total time, F(2, 98) = 6.779, p< .05. Post hoc multiple

comparisons revealed that non-completers had significantly longer duration of drug and

alcohol problems than both completers and graduates. Completers and graduates did not

significantly differ from one another with regard to duration of substance abuse

problems.
 50
Figure 1. Length of Drug/Alcohol Problem

25

20

15
Years

10

0
Noncompleters Completers Graduates
Completion Status

Figure 240. How long with drug and alcohol problems-graduate status.
 51

Table 3

Testing Primary Hypotheses (N=136)

Variable Non-Completer Completer Graduate n F χ2

BDI-II 13.9 13.2 13 0.133

Employmenta 6.86 6.27 5.58 0.465
Age of Onsetb 14.7 14.1 13.6 1.050
No. of past 0.75 0.56 0.35 0.417

hospitalizations
61.6 70.2 70.3 35.60

GAF scoresc *
Jail timed 10.7 5.1 11.6 2.570
No. of arrests 8.2 5 9.3 1.440
No. of drug and 2.1 2 2.2 0.087

alcohol programs
No. of medical 5.04 5.13 4.47 1.170

issues
No. of years 22.5 16.6 8.8 6.780

addicted *
Agee 48.8 48.5 48.7 0.502

(table continues)
Table 3 (continued)

Variable Non-Completer Completer Graduate n F χ2

Gender .502
47 53 32 13

Male 2
Female 1 1 2 4
.

Ethnicity 521
African 22 24 16 62
 52

American
Caucasian 22 27 12 61
Hispanic 3 2 3 8
Other 0 1 4 5 .
.

Marital status 733

Divorced 24 29 17 70
Married 2 4 2 8
Separated 6 4 0 10
Single 16 17 15 48
.

Religion 729
Catholic 5 8 9 22
Christian 26 29 17 72
(table continues)
Table 3 (continued)

Variable Non-Completer Completer Graduate n F χ2

Religion

(continued) 4 2 3 9

Protestant
Other 3 1 0 4
None specified 10 11 5 26
.

Education/Grade 366
Seven 0 1 0 1
Nine 0 3 1 4
Ten 4 6 2 12
Eleven 9 7 4 20
Twelve 25 19 18 62
Thirteen 0 5 4 9
Fourteen 7 7 4 18
Fifteen 2 1 0 3
Sixteen 1 3 0 4
Eighteen 0 0 1 1
Twenty 0 1 0 1
a b c
in the last 10 years. mean age at onset. GAF=Global Assessment of Functioning.
 53

d
measured in months. e mean age.

* significantly different.

CHAPTER

V. DISCUSSION

This study examined the relationship between patient pre-treatment variables and

treatment outcome in the Homeless Veterans Rehabilitation Program. Specifically, we

studied whether baseline characteristics predicted whether patients graduated, completed,

or did not complete the program. Only two variables were found to be associated with

treatment completion status. Higher baseline global assessment of functioning scores and

fewer years of drug and alcohol problems were associated with better program outcomes.

A number of variables were not significantly related to program outcome, including age,

marital status, educational status, employment, age of onset, number of medical issues,

number of previous psychiatric hospitalizations, number of previous drug and alcohol

treatment episodes, criminality (which was measured by number of previous arrests and

amount of total jail time), depressive symptoms, and ethnicity. The discussion section of

this paper will review the primary study findings, the study’s limitations, the clinical

implications and the future directions of this research.

Significant Findings

Those with higher GAF scores upon program entry had more successful treatment

outcomes. Those who went on to graduate (6 month program plus 13 weeks of aftercare)

began treatment with a mean GAF of 70.3. Those who completed the program but did not

complete the aftercare began treatment with a GAF of 70.2. Those who did not complete
 54

the program began with a GAF of 61.6, significantly lower than the GAF of either

completers or graduates. Previous research has emphasized the importance of GAF scores

in predicting treatment outcome. For instance, Earnest (2002) found that treatment

completers had higher GAF scores than non-completers in a study of adolescents

receiving mental health intervention in a naturalistic setting (Earnest, 2002). Considered

together, these findings suggest that lower functioning patients may have a more difficult

time completing treatment and have poorer long-term outcomes.

We found that our group of non-completers had a longer duration of drug and/or

alcohol problems than completers or graduates. In the recent HVRP follow-up study

(Harris et al., 2003), non-completers were more likely to relapse, to be unemployed, and

to be homeless. Thus, it appears that those patients with longer standing drug and alcohol

problems may be less likely to complete this residential treatment program and have

poorer long-term outcomes. This idea is consistent with previous findings that greater

frequency, severity, amount of use and amount of time of abuse are associated with

negative treatment outcome (Condelli & Hubbard, 1994; Ciraulo, Piechniczek-Buzek, &

Iscan, 2003). Ingmar et al. (1999) studied a number of potential predictor variables

regarding the outcome of patient detoxification. Length of time individuals had substance

abuse issues was shown to be the best predictor of a negative outcome of detoxification.

One possible reason for the current and previous findings may that longer duration of

substance abuse may erode support and occupational functioning and be associated with

marital and employment status (Kedia & Williams, 2003). The longer an individual has

an addictive problem, the greater the likelihood that employment, co-morbidity and

relationship issues arise. However, the current study did look at these potentially
 55

confounding variables and found that they were not associated with treatment outcome in

this population.

It is unclear whether these two factors (duration of substance abuse problems and

GAF scores) are two distinct measures or are in fact related. It may be that both lower

levels of functioning and longer history of substance abuse issues simply reflect more

severe substance use problems.

Non-Significant Findings

Age, Gender and Education

We found that age, gender, and educational status were not related to treatment

completion. Studies of the link between demographic factors and treatment outcome have

yielded mixed results (Baskin et al., 1983; Blaney et al., 1975; Farnworth, 1993; Greene,

Ryser, Spillane, & Bardine 1978; Sells et al. 1979; Shuckit, 1985). In 1975, Baekeland

and Lundwall concluded that among demographic variables, only “young” age was

consistently associated with treatment dropout in school and drug abuse individuals

(Backeland & Lundwall, 1975). Keil, Usui and Busch (1982) found that treatment

repeaters tended to suffer from low educational achievement. Similarly, a study by

Schuckit (1985) reported that males at an inpatient facility who were older, more

religious, and better educated were more apt to have a positive outcome 12 months after

discharge than their younger, less educated, and less religious counterparts (Farnsworth,

1993).

One possible reason we did not find a significant difference may be the lack of

variability in the age of our participants - most participants were within one standard
 56

deviation of the mean, with very few participants in the older and younger ends of the

distribution. Similarly, our sample was vastly skewed toward male participants. Out of

136 participants there were 4 females and 132 males, making it impossible to evaluate

gender as a predictor of outcome regarding education, again there was little statistical

variance between the participants. Thus, it is unclear whether our null finding with regard

to demographic variables was a function of a true lack of association or an artifact of our

particular sample characteristics.

Employment Status

Our current study evidenced no significant differences in employment status

across non-completers, completers, and graduates. Some studies have found that

employment variables had a positive correlation to outcome (Mayer & Myerson, 1970;

Vaillant, 1973, 2000), while others have failed to fine such a relationship (Ornstein &

Cherepon, 1985). One possible reason that we did not find employment to be predictive

of outcome may have been the method we used to measure employment status. We

counted the number of jobs participants held in the last 10 years, rather than the duration

or amount of time (in months or years) employed. While we intended to measure

occupational success, our measure of number of jobs may have actually been a marker of

inability to maintain employment. Another possibility is that people who enter the HVRP

program are by definition, homeless and virtually all are substance dependent. In this

population these other variables may be far more determinant than employment status in

how functional and successful a veteran is in the program. The extremity of the current

life situation of the veteran may be more important in determining program utilization

than historical factors such as employment history. In summary, our failure to find a
 57

significant relationship between employment and treatment completion status may be due

to our operationalization of this variable and/or due to the severe impairment of our

sample.

Marital Status

This study evidenced no significant differences in marital status across the 3

treatment outcome groups. This may have been a direct result of the small sample size

and the uneven distribution of marital status. Only 8 of 136 participants reported that they

were married upon admission to treatment. Due to the increased attention given to family

system theories, there has been a recent surge in research focusing upon factors assessing

the quality of, and the stability of the current marital relationship. Moos and Moos (1976)

found that a “vicious cycle” develops in which family issues initiate or trigger drinking

and the consequences of drinking further aggravate the family problems. LaJeunesse and

Thoreson (1988) found that factors associated with the quality of patient’s marital

relationship were the most predictive of all variables that were investigated. These

researchers’ observations were that one’s marital status, spouse’s drinking status, quality

of marriage, and living arrangement were shown to be the best predictors of positive

outcome behavior for drinking. Additionally, they found that the number of marriages

was a mild to moderate predictor of positive outcome. When taken together, these data

collected from a number of previous investigations were supportive of the notion that

marital problems may lead to a prediction of unsuccessful post-treatment outcome

(LaJeunesse & Thoreson, 1988). Due to the strength of this factor in the literature it

would be useful to evaluate the predictive power of marital status with a larger, more

balanced sample (with respect to martial status distribution).

 58

Criminality and Legal Involvement

Our hypotheses regarding criminality and legal involvement were not supported;

there were no significant between group differences in the number of arrests and total

time incarcerated. Trice, Roman, and Belasco (1969) found that having few or no arrests

was the single best predictor of successful adjustment subsequent to treatment. Similarly,

Sells (1977) documented that the only factor from their study that was associated with

abstinence following a detoxification program was a low background of criminality.

Farnworth (1993) had also noted that his good prognosis primarily alcoholic group had

fewer antisocial problems and less involvement with the police. However, studies by

Vaillant (1973) and by Baskin and Missouri (1983) found no association between the

number of arrests individuals had amassed with outcome of treatment.

Our current null findings, and the mixed findings regarding criminality and

treatment outcome in the literature, may be due to the variability both in individual

response to involvement with the legal system and in the correctional facility in which the

individual was detained. For example, some prisons and jails have treatment programs,

therapy, visitation, good facilities, etc., whereas others offer very little and may in fact be

demoralizing. It may be that the best way to determine the impact of previous

incarceration on treatment outcome would be to compare treatment outcomes of

individuals who had been through similar incarceration experiences. Another possible

reason we did not find any significance with the criminality variable may be that being on

probation and/or being court ordered may motivate individuals to remain in treatment and

complete the program due to the only other option offered, which in many cases is being

incarcerated.
 59

Psychiatric Hospitalization History

In our current study we found no significant between group differences regarding

the number of previous psychiatric hospitalizations. The mean number of hospitalizations

for all groups was less than 1. Consistently documented in the treatment outcome

literature is the idea that the possession of a comorbid psychiatric diagnosis, independent

of that of substance abuse, is believed to worsen one’s prognosis (Craddock, 1997;

Messina, Wish, & Nemes, 2000). The main premise is that additional pathology suggests

that an individual has fewer resources to cope with the stresses of recovery and may be

more likely to relapse. In one of the earliest studies of pretreatment variables, Trice,

Poman, and Belasco (1969) noted that a history of previous psychiatric hospitalizations

was one of the best predictors of unsuccessful adjustment following an episode of drug

and alcohol treatment. There have been several studies conducted in which the

researchers have examined the relationship between additional psychiatric diagnoses and

treatment outcome success. These studies have found that a diagnosis of antisocial

personality disorder is correlated to poorer outcomes and higher dropout rates

(Baekeland, & Lundwall, 1975; Chang et al., 2001; Moggi et al., 1999; Nunes et al.,

2004).

Our failure to find what has been a somewhat robust finding in the previous

literature may be function of our sample. Although many of the participants have a co-

morbid diagnosis in addition to their primary diagnosis of substance abuse, HVRP is very

careful not to admit individuals with active symptoms of severe psychiatric issues such as

schizophrenia and bipolar disorder. By reducing the variability of psychiatric

comorbidities in those admitted to the program, the stringent admission criteria for our
 60

program may have reduced the likelihood of finding a link between psychiatric problems

and treatment completion.

Age of Onset

There were no significant differences across treatment outcome group regarding

age of onset of drug and alcohol use. Because in this study age of onset was defined as

age at first use (as is commonly done in the literature), there was very little variance as

most participants first tried drugs and/or alcohol between the ages of 13 and 14 years old.

The mean age of onset for non-completers’ was 14.7 years old, whereas the mean age of

completers’ and graduates’ was 14.1 and 13.6 years old. Trice, Roman, and Belasco

(1969) found that later age of first intoxication was predictive of successful adjustment

following a substance abuse treatment episode. In 1985, Schuckit found that his group of

primary alcoholics tended to have a later age of onset of substance abuse and that this

was associated with positive outcomes 12 months after discharge. However, Baskin and

Missouri (1983) found that age at first use was not predictive of success in an alcohol

halfway house program. However, Holland and Evenson (1984) found that residents’

requiring readmission were more likely than successful discharge patients to date the

initiation of problem drinking to between the ages of 20-29 rather than later

(Farnsworth,1993), suggesting that onset of drug or alcohol related problems may be a

relevant time point to examine. Our operationalization of this variable may account for

our null findings. We might have better answered this question had we looked at onset of

substance abuse/dependence symptoms and/or life style disruption.

 61

Depression and Treatment Outcome

There were no significant differences in baseline depressive symptoms across the

three treatment outcome groups. While elevated rates of depression have been found

among individuals with addictive disorders, the impact of BDI scores on outcome has

yielded conflicting results. Some outcome studies have found worse prognoses in patients

with co-morbid depression (Bovasso, 2001) while others have found no relation between

depression and treatment outcome (Paraherakis, 1997). Still others show that concomitant

depression may predict better outcomes among women (Rounsaville et al., 1987), longer

treatment retention among cocaine addicted men (Paraherakis, 1997), and greater

attendance to therapy sessions in methadone patients (Joe et al., 1998).

One possibility for our non-significant results may be the low level of depressive

symptoms in our overall sample. The mean BDI score of 13.4 suggests only a mild level

of depression... Few participants involved in the study tested in the severely depressed

diagnostic range. A larger sample with more variance in depressive symptoms may have

been a better test of this hypothesis. Because the results in the literature are so mixed, it is

possible if not likely that other factors are involved such as type of depression and/or

trauma, and/or anxiety etc. It is evident that further research is required in order to clarify

the impact of depression on treatment outcome of addicted individuals (Paraherakis,

1997).

Number of Substance Abuse Treatment Episodes

Our hypothesis that non-completers’ would have a higher number of treatment

episodes was not supported - there were no statistically significant differences across the

three groups. The mean number of substance abuse treatment episodes or previous
 62

programs was 2.1 for the entire population tested in this study. The literature has been

mixed regarding the relationship between the actual number of times individuals have

experienced treatment and current treatment outcome. Baskin and Missouri (1983) found

that the number of treatment episodes had no relationship to treatment failure. This

finding has been corroborated with 2 different populations by Blaney, Radford, and

MacKenzie (1975). However, Holland and Evenson (1984) found a relationship between

the number of treatment episodes and recidivism, but only if the individual had refused

follow-up treatment/aftercare. Confirming these findings, Ornstein and Cherepon (1985)

have also noted that there was a small but significant correlation between patient

likelihood to participate in aftercare and post positive drinking status. This is

corroborated by these data from our previous HVRP follow-up study which evidenced

significant differences on all three measures (abstinence, employment and housing) with

our group that attended and completed aftercare (graduates). The difference between a

graduate and a completer is that a graduate participates in 13 weeks of aftercare treatment

whereas a completer does not.

It appears as though the number of treatments alone has no relationship to

outcome, while the decision to participate in aftercare therapy may be important.

Additionally, while the number of episodes may not be meaningful, the total amount of

treatment may have been a more meaningful way to measure this variable. For example,

one completed 6 month program may correlate with a more successful outcome than 10

episodes that totaled less cumulative time.

 63

Limitations

There are, in fact, several limitations to this study that should be considered. First,

the generalizability of the study is limited, given that it included a single residential

treatment site with a select population. These data were drawn from a single system of

care targeting a mostly male, homeless population. Because HVRP is a program for the

homeless, housing status (length of time without housing) may be a critical determinant

of program outcome in this population. These data were not available to measure the

effect on this variable. Second, there may have been an issue with inter-rater reliability in

that the data had been collected originally for clinical purposes only, so there may have

been some variance in the data that was created by differences between raters rather than

by actual differences in the patients.

Third, our operationalization of several study constructs could have been

improved. We measured the number of substance abuse treatment episodes as the number

of times an individual entered treatment. A treatment episode could have lasted for as

little as one day or as long as one year. The literature is quite consistent regarding length

of treatment stays and how length of time correlates with successful outcome, so it may

have been beneficial to know how long (counting in days) each treatment episode

actually lasted. Similarly, as noted previously, we could have improved our measurement

of age of onset of substance abuse problems (using age of onset with age when

substances became to be maladaptive coping strategies and not just the age when the

person first used a substance) and our measurement of past employment (instead of

counting the number of previous jobs in the past 10 years, if we counted the number of

time in days, weeks, months and years the individual had been employed. .
 64

Fourth, our relatively small sample size and limited variability with regard to

many of the variables in question (e.g., BDI scores, previous number of psychiatric

hospitalizations, previous number of substance abuse treatment episodes, age, educational

status, employment status and age of onset) may have reduced our power to detect

significant results. The results may have differed if we had a larger, more heterogeneous

population.

Clinical Implications

There are several implications for the findings of this study, both for the

Homeless Veterans Rehabilitation Program (HVRP) and for the field in general. Results

of this study may help program administrators and clinicians reduce attention to baseline

characteristics that are not predictive of successful program completion. The results from

this study challenge therapists and researchers in residential settings to think beyond

static variables and avoid “profiling” or developing a picture of what specific pre-

treatment characteristics will predict for treatment completion/graduation. That which

does not predict treatment completion/graduation (e.g., fixed conditions such as race, age,

and family constellation), forces residential program administrators and therapists to

think about their own biases. For example, knowing that a new admission has had an

extensive history of prior court involvement could possibly activate a clinician’s biases

about whether or not the individual is capable of completing/graduating from a

community-based program. In fact, these data indicate that this is not the case. The fact

that there were no significant differences across age, race, educational status, marital

status, criminality, BDI scores, previous number of jobs within the past 10 years, age of

onset, medical problems, previous number of psychiatric hospital stays and previous
 65

number of substance abuse programs, may be viewed as a positive finding, suggesting

that the program is equally effective in a diverse population of lower functioning adults.

If in fact the substance abuse treatment clinical approach to HVRP is effective with

diverse populations, then this model of treatment could be implemented elsewhere and in

other mental health facilities. Additionally, based on these data, another clinical

implication may be that lower functioning individuals tend to have less successful

outcomes, which in turn may indicate that HVRP may not be appropriate for these lower

functioning people. This last possibility leads to suggestions such as either, not admitting

the lower functioning individuals or adding a remedial track to the HVRP structure

making the program much more doable to these lower functioning people.

Future Directions

The findings and limitations of the present study suggest some directions for

future research. One possible next step could be to replicate this study using the entire

population of individuals that participated in the HVRP 2,003 follow-up study instead of

only a portion of the population. That would increase the N from 136 to over 500 and

possibly give a general sense of what predicts completion at HVRP overall. Another

possibility for future research could be to run new analyses on the full follow-up sample

for which we have pre-treatment data up to the present. We could then do a pre-treatment

investigation on them so that we could specifically state for a given sample the extent to

which post-treatment differences were due to pre-treatment characteristics. These studies

would allow us to conclude that the HVRP program essentially works, since those

patients who complete and graduate fare better, and our results would not be based on

pre-treatment differences.
 66

Summary

This study attempted to verify pre-treatment characteristic variables that would

predict successful treatment completion/graduation from a specific residential treatment

program. Higher baseline functioning (i.e., GAF scores) and shorter duration of substance

abuse problems were associated with more successful treatment outcomes. There are

several positive aspects to this study. The fact that there were no significant differences

across age, race, educational status, marital status, criminality, BDI scores, previous

number of jobs within the past 10 years, age of onset, medical problems, previous

number of psychiatric hospital stays and previous number of substance abuse programs,

may be viewed as a positive finding, suggesting that the program is equally effective in a

diverse population of lower functioning adults. In the final analysis, our attempt to

answer the question, are post-treatment differences a function of pre-treatment

characteristics has left us with no black or white answer. After analyzing these data the

correct answer appears to be both yes and no. We studied a total of 13 pre-treatment

variables finding 2 of them statistically significant and 11 of them to be statistically non-

significant. Additionally, our findings corroborate much of the previous literature

suggesting that length of time in the program and completing/graduating has positive

treatment benefits.

In the era of managed care, services with the monetary costs of residential

treatment will become less prevalent. However, one certainty remains—individuals’ with

substance abuse will continue to require the services of mental health professionals.

Accordingly, much research remains to be done in order to discover the best possible
 67

match of services while responsibly meeting the needs of each individual, thus

maximizing the utility of each system of care.

 68

REFERENCES

Alterman, A. I., McLellan, A. T., & Shifman, R. B. (1993). Do substance abuse patients

with more psychopathology receive more treatment? Journal of Nervous and

Mental Disease, 181, 576-582.

Anglin , M. D., & Hser, Y. (1990). Treatment of drug abuse. In : M. Tonry and J. Q.

Wilson (Eds.) Crime and Justice: An Annual Review of Research, Vol. 13: Drugs

and Crime. Chicago, Illinois: University of Chicago Press.

Anglin, M. D., Hser, Y. I., & Grella, C. E. (1997). Drug addiction and treatment careers

among clients in the drug abuse treatment outcome study (DATOS). Psychology

of Addictive Behaviors, 11(4), 308-323.

Baekeland, F., Lundwall, L. (1975). Dropping out of treatment: A critical review.

Psychological Bulletin, 82, 738-783.

Bachman, J. G., Wallace, J. M., O’Malley, P. M., Johnson, L. D., Kurth, C. L., &

Neighbors, H. W. (1991). Racial/ethnic differences in smoking, drinking, and

illicit drug use among American high school seniors, 1976-1989. American

Journal of Public Health, 81(3), 372-377.

Bandura, A. (1977). Social Learning Theory. New York: General Learning Press.

Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in

social psychological research: Conceptual, strategic, and statistical considerations.

Journal of Personality and Social Psychology, 51, 1173-1182.

 69

Baskin, D., & Missouri, C. (1983). A treatment outcome study of alcohol halfway house

residents in the South Bronx. International Journal of the Addictions, 18(4), 551-

558.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of

depression. New York: Guilford.

Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.

Beck., A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the beck

depression inventory: Twenty-five years of evaluation. Clinical Psychology

Review, 8(1), 77-100.

Benda, B. B. (2001). Predictors of re-hospitalization of military veterans who abuse

substances. Social Work Research, 25(4), 199-204.

Berry, P. E., & Anderson, R. (2001). An evaluation of a private alternative probation and

counseling program: Predicting program outcomes from client characteristics.

American Journal of Criminal Justice, 26(1), 121-130.

Bleiberg, J. L., Devlin, P., Croan, J., & Briscoe, R. (1994). Relationship between

treatment length and outcome in a therapeutic community. The International

Journal of the Addictions, 29(6), 729-740.

Blum, T. C., Roman, P. M., & Martin, J. K. (1993). Alcohol consumption and work

performance. Journal of Studies on Alcohol, 54, 61-70.

 70

Botvin, G. J., Baker, E. Dusenbury, L., Tortu, S., & Botvin, E. M. (1990). Preventing

adolescent drug abuse through a multimodal cognitive-behavioral approach:

Results of a 3-year study. Journal of Consulting and Clinical Psychology, 58(4),

437-446.

Bovasso, G. (2001). The long-term treatment outcomes of depression and anxiety co-

morbid with substance abuse. The Journal of Behavioral Health Services &

Research, 28(1), 42-58.

Brewer, D. D., Catalano, R. F., Haggety, K., Gainey, R.R., & Fleming, C. B. (1998). A

meta-analysis of predictors of continued drug use during and after treatment for

opiate addiction. Addiction, 93(1), 73-92.

Brickman, P., Rabinowitz, V. C., Karuza, J., Coates, D., Cohn, E., & Kidder, L. (1982).

Models of helping and coping. American Psychologist, 37, 368-384.

Broekaert, E. (2001). Therapeutic communities for drug users. Description and overview.

In B. Rawlings, and R. Yates (Eds.), Therapeutic Communities for the Treatment

of Drug Users, (pp. 29-42). London and Philadelphia: Jessica Kingsley

Publishers.

Brown, R. A., & Ramsey, S. E. (2000). Addressing co-morbid depressive

symptomatology in alcohol treatment. Professional Psychology: Research and

Practice, 31(4), 418-422.

 71

Brown, S. A., Tarpert, S. F., Granholm, E., & Delis, D. C. (2000). Neurocognitive

functioning of adolescents protracted alcohol use. Alcoholism: Clinical and

Experimental Research, 24(2), 164-171.

Burdon, W. M., Messina, N. P., & Prendergast, M. L. (2004). The California treatment

expansion initiative: Aftercare participation, recidivism, and predictors of

outcomes. The Prison Journal, 8, 61-80.

Burling, T. A., Seidner, A. L., Salvio, M., & Marshall, G.D. (1994). A cognitive –

behavioral therapeutic community for substance dependent and homeless

veterans: Treatment outcome. Addictive Behaviors, 19(6), 621-629.

Caplehorn, J. R. M., Lumley, T. S., & Irwig, L. (1998). Staff attitudes and retention of

patients in methadone maintenance programs. Drug and Alcohol Dependence,

52(1), 57-61.

Catalano, R. F., Wells, E. A., Hawkins, J. D., Miller, J.L., & Brewer, D.D. (1990-1991).

Evaluation of the effectiveness of drug abuse treatment, assessment of risks for

relapse, and promising approaches for relapse prevention, International Journal

of the Addictions, 25, 1085-1140.

Chang, C. M., Lee, Y., Lee, Y., Yang, M . J., & Wen, J. K. (2001). Predictors of

readmission to a medical-psychiatric unit among patients with minor mental

disorders. Chang Gung Medical Journal, 24(1), 34-43.

 72

Chou, C., Hser, Y. & Anglin, M.D. (1998). Interaction effects of client and treatment

program characteristics on retention: An exploratory analysis using hierarchical

linear models. Substance Use and Misuse, 33, 2281-2301.

Ciraulo, D. A., Piechniczek-Buczek, J., & Iscan, E. N. (2003). Outcome predictors in

substance use disorders. Psychiatric Clinician of North America, 26(2), 381-409.

Compton III, W. M., Cottler, L. B., Jacobs, J. L., Ben-Abdallah, A., & Spitznagel, E. L.

(2003). The role of psychiatric disorders in drug dependence treatment outcomes.

The American Journal of Psychology, 160(5), 890-896.

Condelli, W. S. & Hubbard, R. L. (1994). Relationship between time spent in treatment

and client outcome in therapeutic communities. Journal of Substance Abuse

Treatment, 11, 25-33.

Condelli, W, S., & Dunteman, G. H. (2002). Issues to consider when predicting retention

in therapeutic communites. American Journal of Drug and Alcohol Abuse. 28(1),

55-72.

Correctional Service of Canada (1990). Effective treatment for drug and alcohol

problems: What do we know? Correctional Service of Canada, 2(4), 1-10.

Costello, R. M. (1975). Alcoholism treatment and evaluation: In search of all methods. II.

Collation of two year follow-up studies. International Journal of the Addictions,

10, 857-867.
 73

Craddock, S. G. (1997). Characteristics and pretreatment behaviors of clients entering

drug abuse treatment: 1969 to 1993. American Journal of Drug and Alcohol

Abuse, 23(1), 43-59.

De Leon. G. (1985). The therapeutic community: Status and evolution. International

Journal of the Addictions, 7, 823-844.

De Leon, G. (1991). Retention in drug-free therapeutic communities. International

Journal of the Addictions, 25, 1229-1241.

De Leon, G. (Ed). (1994b). Therapeutic communities. In M. Galanter & H. D. Kleber,

(Eds), The American Psychiatric Press Textbook of Substance Abuse Treatment

(pp. 391-414). Chicago: American Psychiatric Press.

De Leon, G. (1997). Community as method: Therapeutic communities for special

populations and special settings. Westport, CT: Greenwood Press.

DeLeon, G., & Schwartz, S. (1984). Therapeutic communities: What are the retention

rates? American Journal of Drug and Alcohol Abuse, 10(2), 267-284.

Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005). The duration and correlates

of addiction and treatment. Journal of Substance Abuse Treatment, 28(1), 51-62.

Earnest, L. (2002). Long-term outcomes of early childhood mental health services.

Dissertation Abstracts International, 63 (06), 3005B. (UMI No. 3058736).

 74

Farnsworth, R. B. (1993). The prediction of alcohol treatment completion as a function of

addiction severity, psychological type, and expectancies: Toward a predictive

screening device for alcohol treatment. Dissertation Abstracts International, 55

(05), 2006B. (UMI No. 9426913).

Farrokh, A. Stephens, R. C., Llorens, S., & Orris, B. (1995). A review of factors affecting

treatment outcomes: Expected treatment outcome scale. American Journal of

Drug and Alcohol Abuse, 17, 448-552.

Finigan, M. (1996). Northwest Professional Consortium. (1996, February). Societal

outcomes and cost savings of drug and alcohol treatment in the state of Oregon.

Portland, OR: Retrieved Feb 23, 2005 from

Http:www.drugabusestatistics.samhsa.gov

Fleming, M. F., & Barry, K. L. (1992). Clinical overview of alcohol and drug disorders.

In M. F. Fleming, & K. L. Barry, K. L. (Eds.), Addictive disorders (pp. 3-21).

Chicago: Mosby.

Fortuin-Corsi, K., Kwiatkowski, C. F., & Booth, R. E. (2002). Predictors of positive

outcomes for out-of-treatment opiate injectors recruited into methadone

maintenance through street outreach. Journal of Drug Issues, 32(3), 999-1016.

Gerstein, D. R. & Harwood, H. J. (Eds.) 1990. Treating drug problems, (vol. 1).

Washington, DC: National Academy Press.

 75

Gerstein, D. R., & Johnson, R. A. (1999). The surgeon general’s report: Adolescent and

youth adults in the national improvement evaluation study: Substance use

disorders in adolescents. National Evaluation Data Services. Retrieved January 4,

2006, from the NEDS database.

Goethe, E., Weinstein, S. P., Sterling, R. C., & Lundy, R. D. (1998). A randomized

controlled study of the effectiveness of intensive outpatient treatment of cocaine

dependence. Psychiatric Services, 49, 782-787.

Gonzalez, G. M. (1989). Effects of raising the drinking age among college students in

Florida. College Student Journal, 23(1), 62-75.

Gordis, E., & Fuller, R. (1999). Comments on Project Match: Matching alcohol

treatments to client heterogeneity. Addiction, 94(1), 57-60.

Greene, B. T., Ryser, P. E., Spillane, W. H., & Bardine, A. (1978). Effects of client

characteristics on admission actively in United States federally funded drug

treatment facilities. The International Journal on Addiction, 13, 1103-1126.

Grella, C. E., Hser, Y., Joshi, V., & Anglin, M.D. (1999). Patient histories, retention, and

outcome models for younger and older adults in datos. Drug and Alcohol

Dependence, 57, 151-166.

Groth-Marnat, G. (1990). The handbook of psychological assessment (2nd ed.). New

York: John Wiley & Sons.

 76

Harrell, A., & Roman, J. (2001). Reducing drug use and crime among offenders: The

impact of graduated sanctions. Journal of Drug Issues, 31(1), 207-232.

Harris, K.W., Schauder, B., Wain, R. M., Ferber, L. M., Malcus, L. & Burling, T. A.

(2005). The role of program completion and aftercare in domiciliary treatment

outcome. In J. Johnson (Chair), Current Research in Group Psychotherapy.

Symposium conducted at the meeting of the American Group Psychotherapy

Association, Chicago, IL.

Hartley, R. E., & Phillips, R. C. (2001). Who graduates from drug courts? American

Journal of Criminal Justice, 26(1), 107-119.

Hawkins, J. D., & Catalano, R. F., (1985). Aftercare in drug abuse treatment,

International Journal of the Addiction, 20, 917-945.

Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for

alcohol and other drug problems in adolescence and early adulthood: Implications

for substance abuse prevention. Psychological Bulletin, 112(1), 54-105.

Heather, N., Batey, R., Saunders, J. B., & Wodak, A. D. (1989). The effectiveness of

treatment for drug and alcohol problems: An overview monograph series no. 11.

Commonwealth Department of Community Services and Health for the National

Campaign Against Drug Abuse. NCADA Monograph Series.

Henggeler, D. E., Pickrell, L. F., Brondino, S., A. (1996). The effectiveness of substance

abuse treatment with young offenders. Research and Statistics., 127, 334-449.
 77

Hiller, M. L., Knight, K., Devereux, J., & Hathcoat, M (1996). Post-treatment outcomes

for substance-abusing probationers mandated to residential treatment. Journal of

Psychoactive Drugs, 28(3), 291-296.

Hodgins, D. C., & El-Guebaly, N. (1992). More data on the addiction severity index.

Journal of Nervous and Mental Disorders, 180, 197-201.

Howard, K. I., Cox, W. M., & Saunders, S. M. (1990). Attrition in substance abuse

comparative treatment research: The illusion of randomization. NIDA Research

Monograph, 104, 91-1722.

Hser, Y. I., Joshi, V., Anglin, M. D., & Fletcher, B. (1999). Predicting post-treatment

cocaine abstinence for first-time admissions and treatment repeaters. American

Journal of Public Health, 89(5), 666-671.

Hser, Y. I., Huang, D., Teruya, C., & Anglin, M. D. (2003). Gender comparisons of drug

abuse treatment outcomes and predictors. Drug and Alcohol Dependence, 72(3),

255-264.

Hser, Y. I., Evans, M. A., Huang, D., & Anglin, D. M. (2004). Relationship between drug

treatment services, retention, and outcomes. Psychiatric Services, 55(7), 767-774.

Hubbard, R. L., Cavanaugh, E. R., Craddock, S. G., & Rachal, J. V. (1985).

Characteristics, behaviors, and outcomes for youth in the TOPS. In A. S.

Friedman & G. M. Beschner (Eds.), Treatment Services for Adolescent Substance

Abusers. (pp.1-45). Rockville, MD: National Institute on Drug Abuse.

 78

Ingmar, H. A., Franken, M. Sc., & Hendricks, V. (1999). Predicting outcome of inpatient

detoxification of substance abusers. Psychiatric Services, 50, 813-817.

Ito, J., Donovan, D., & Hall, J. (1988). Relapse prevention in alcohol aftercare: Effects on

drinking outcome, change process, and aftercare attendance. British Journal of

Addictions, 83, 171-181.

Jacobson, J. O. (2004). Place and attrition from substance abuse treatment. Journal of

Drug Issues, 34(1), 23-49.

Jainchill, N., Hawke, J, De Leon, G., & Yagelka, J. (2000). Adolescents in therapeutic

communities: One-year posttreatment outcomes. Journal of Psychoactive Drugs,

32(1), 81-94.

Jaycox, L. H., Marshall, G. N., & Morral, A. R. (2002). Effectiveness of community-

based treatment for substance abusing adolescents: 12-month outcomes from a

case-control evaluation of a phoenix academy. Phoenix Academy at Lake View

Terrace, CA: Clinical Manual & Program Description of an Adolescent

Therapeutic Community. Santa Monica: RAND.

Joe, G. W., Simpson, D. D., & Broome, K. M. (1998). Effects of readiness for drug abuse

treatment on client retention and assessment of process. Addiction, 93(8), 1177-

1190.
 79

Johnson, K., Bryant, D. D., Collins, D. A., Noe, T. D., Strader, T. N., & Berbaum, M.

(1998). Preventing and reducing alcohol and other drug use among high-risk

youths by increasing family resilience. Social Work, 43(4), 297-308.

Johnson, C. A., & Solis, J. (1983). Comprehensive community programs for drug abuse

prevention: Implications of the community heart disease prevention program for

future research. In T. J. Glynn, C. G. Gleukefeld, & J. P. Ludford (Eds).

Preventing adolescent drug abuse Research Monograph number 47, 76-114.

Kaminer, Y. (2001). Alcohol & drug abuse: Adolescent substance abuse treatment:

Where do we go from here? Psychiatric Services, 52, 147-149.

Kandel, D., Simcha-Fagan, O., & Davies, M. (1986). Risk factors for delinquency and

illicit drug use from adolescence to young adult-hood. The Journal of Drug

Issues, 16, 67-90.

Kaplow, J. B., Curran, P. J., & Dodge, K. A. (2002). Child, parent and peer predictors of

early-onset substance use: A multisite longitudinal study. Journal of Abnormal

Child Psychology, 30(3), 199-216.

Kedia, S., & Williams, C. (2003). Predictors of substance abuse treatment outcomes in

Tennessee. Journal of Drug Education, 33(1), 25-47.

Klein, C., Menza, S. di., Arfken, C., & Schuster, C. R. (2002). Interaction effects of

treatment setting and client characteristics on retention and completion. Journal

of Psychoactive Drugs, 34(1), 39-51.

 80

Kleinman, P. H., Kan, S. Y., Lipton, D. S., Woody, G. E., Kemp, J., & Millman, R. B.

(1992). Retention of cocaine abusers in outpatient psychotherapy. American

Journal of Drug and Alcohol Abuse, 18(1), 29-43.

Knapp, J. E., Templer, D. I., Cannon, G. W., & Dobson, S. (1991). Variables associated

with success in an adolescent drug treatment program. Adolescence, 26, 305-317.

LaJeunesse, C. A., & Thoreson, R. M. (1988). Generalizing a predictor of male alcoholic

treatment outcomes. International Journal of Addiction, 23,183-205.

Lanham-Travers, L. (2003) Demographic indicators and patterns of substance use, abuse,

and dependence in a rural frontier setting. Dissertations Abstracts International,

63 (09), 3118A. (UMI No. 3064801)

Lash, S. J. (1998). Increasing participation in substance abuse aftercare treatment.

American Journal of Drug and Alcohol Abuse, 22, 440-452.

Laudet, A. B., Savage, R., & Mahwood, D. (2002). Pathways to long-term recovery: A

preliminary investigation. Journal of Psychoactive Drugs, 34, 305-311.

Layden, M. A., Newman, C. F., Freeman, A., & Byers Morse, S. (1993). Cognitive

therapy of borderline personality disorder. Boston: Allyn & Bacon.

Leonhard, C., Mulvey, K,. Gastfriend, D. R., & Schwartz, M. (2000). The addiction

severity index: A field study of internal consistency and validity. Journal of

Substance Abuse Treatment, 18(2), 139-135.

Leshner, A. (1997). Addiction is a brain disease, and it matters. Science, 2(78), 45-47.
 81

Luke, D. A., Mowbray, C. T., Klump, K., Herman, S. E., & BootsMiller, B. (1999).

Exploring the diversity of dual diagnosis: Utility of cluster analysis for program

planning. Journal of Mental Health Administration, 23, 298-316.

Lynskey, M. T., Heath, A. C., Bucholz, K. K., Slutske, W. S., Madden, P. A., Nelson, E.

C., Statham, D. J., & Martin, N. G. (2003). Escalation of drug use in early-onset

cannabis users vs co-twin controls. Journal of the American Medical Association,

289(4), 427-433.

Maglione, M., Chao, B. S., & Anglin, M. D. (2000). Correlates of outpatient drug

treatment drop-out among methamphetamine users. Journal of Psychoactive

Drugs, 32(2), 221-228.

Magura, S., Nwakeze, P. C., & Demsky, S. (1998). Pre- and in-treatment predictors of

retention in methadone treatment using survival analysis. Addiction, 93, 51-61.

Makela, K., & Mustonen, H. (1988). Positive and negative consequences related to

drinking as a function of annual alcohol intake. British Journal of Addictions, 83,

403-408.

March, J. S., & Curry, J. F. (1998). Predicting the outcome of treatment. Journal of

Abnormal Child Psychology, 26(1), 39-51.

Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention: Maintenance strategies in

the treatment of addictive behaviors. New York: Guilford.

 82

Marlowe, D. B. (2004). Drug court efficacy vs. effectiveness. Join Together Online.

Retrieved January11, 2006 from

http://wwwjointogether.org/sa/news/features/reader/0.1854.574745.00.html

Martin, S. S., Butzin, C. A., Saum, C. A., & Incardi, J. A. (1999). Three-year outcomes of

therapeutic community treatment for drug-involved offenders in Delaware: From

prison to work release to aftercare. The Prison Journal, 79(3), 294-320.

Mayer, J., & Myerson, D. J. (1970). Characteristics of outpatient alcoholics in relation to

change in drinking, work, and marital status during treatment. Quarterly Journal

of Studies on Alcohol, 31, 889-897.

McKay, J. R. (2001). The role of continuing care in outpatient alcohol treatment

programs. The Journal of Recent Developmental Alcohol Issues, 15, 357-372.

McKay, J., Maisto, S., & O’Farrell, T. (1993). End of treatment self efficacy, aftercare,

and drinking outcomes of alcoholic men. Alcoholism, Clinical, and Experimental

Research, 17(3), 1078-1083.

McLellan, A.T., (1983). Patient characteristics associated with outcome. In Cooper, J. R.,

Altman, F., Brown, B. S., & Chechowicz, D. (Eds.) Research on the treatment of

narcotic addiction: State of the art, NIDA Research Monograph, No. ADM 83-

1281, 500-529.
 83

McLellan, A. T. (1993). Psychosocial services in substance abuse treatment? A dose-

ranging study of psychosocial services. Journal of Medical Association, 269(15),

1953-1959.

Messina, N., Wish, E., & Nemes, S. (2000). Predictors of treatment outcomes in men and

women admitted to a therapeutic community. American Journal of Drug and

Alcohol Abuse, 26(2), 207-227.

Moggi, F., Ouimette, P.C., Finney, J.W., & Moos, R. H. (1999). Effectiveness of

treatment for substance abuse and dependence for dual diagnosis patients: A

model of treatment factors associated with one-year outcomes. Journal of Studies

on Alcohol, 60, 856-866.

Moos, R. A. & Moos, B. S. (1976) A Typology of family social environment. Family

Process, 15, 357-371.

Moos, R. H., Pettit, B., & Gruber, V. (1995). Longer episodes of community residential

care reduce substance abuse patients’ admission rates. Journal of Studies on

Alcohol, 56(4), 433-443.

Moos, R., Finney, J. W. & Cronkite (2000). Alcoholism Treatment. Context, Process, and

treatment. Oxford: Oxford University Press.

 84

Moos, R. H., Finney, J. W., Federman, E. B., & Suchinsky, R. (2000). Specialty mental

health care improves patients’ outcomes: Findings from a nationwide program to

monitor the quality of care for patients with substance use disorders. Journal of

Studies on Alcohol, 61, 704-713.

Moos, R. H., McCoy, L. & Moos, B. S. (2000). Global assessment of functioning (GAF)

ratings: Determinants and role as predictors of one-year treatment outcomes.

Journal of Clinical Psychology, 56(4), 449-61.

Mueller, M, & Wyman. (1997). Study sheds new light on the state of drug abuse

treatment nationwide. Treatment Research, 12, 1-7.

Mumola, C. J. (1997). Substance abuse and treatment, state and federal prisoners. Bureau

of Justice Statistics Special Report. Washington, DC: Office of Justice Programs,

U. S. Department of Justice, 1997.

Murray, C. J. L., & Lopez, A. D.(1997). Global mortality, disability, and the contribution

of risk factors: Global burden of diseases study. Lancet, 349, 1436-1442.

Nielsen, A. L., & Scarpitti, F. R. (1997). Changing the behavior of substance abusers:

Factors influencing the effectiveness of therapeutic communities. Journal of Drug

Issues, 27(2), 279-299.

Nunes, E. V., & Levin, F. R. (2004). Treatment of depression in patients with alcohol or

other drug dependence: A meta-analysis. JAMA, 291(15), 1887-1987.

 85

Orlando, M., Chan, K. S., & Morral, A. R. (2003). Retention of court-referred youths in

residential treatment programs: Client characteristics and treatment process

effects. American Journal of Drug and Alcohol Abuse, 10(4), 689-695.

Ornstein, P., & Cherepon, A. J. (1985). Demograpic variables as predictors of alcoholic

treatment outcome. Journal of Studies on Alcohol, 46, 425-432.

Paraherakis, A. (1997). Substance-related disorders and associated psychopathology:

Predicting addictions treatment outcome. Masters Abstracts International, 38

(03), 679 (UMI No 800-521-0800). McGill University, Quebec Canada.

Pinchot, T. (2001). Co-creating solutions for substance abuse. Journal of Systemic

Therapies, 20(2), 1-23.

Platt, J. J. (1995). Vocational rehabilitation of drug abusers. Psychological Bulletin,

117(3), 416-433.

Polinsky, M. L. Hser, Y. I., & Grella, C. E. (1998). Consideration of special populations

in the drug treatment system of a large metropolitan area. The Journal of

Behavioral Health Services & Research, 25(1), 7-21.

Project Match Research Group, (1993). Rationale and methods for a multisite clinical

trial matching patients to alcoholism treatment. Alcoholism: Clinical and

Experimental Research, 17, 1130-1145.

 86

Rabinowitz, J., & Marjefsky, S. (1998). Alcohol & drug abuse: Predictors of being

expelled from and dropping out of alcohol treatment. Psychiatric Services, 49,

187-189.

Rachal, J.V., Guess, L. L., Hubbard, R. L., Maisto, S. A., Cavanaugh, E. R., Waddel, R.,

et al. (1982). Facts for planning No. 4: Alcohol misuse by adolescents. Alcohol

Health and Research World, 6(3), 61-68.

Riley, D., Sobell, L., Sobell, L. G., & Klajner, F. (1987). Behavioral treatment of alcohol

problems: A review and comparison of behavioral and non-behavioral studies. In

W. M. Cox (Ed). Treatment and prevention of alcohol problems: A resource

manual. (pp.73-115). San Diego, CA: Academic Press.

Roberts, A. C., & Nishimoto, R. H. (1996). Predicting treatment retention of women

dependent on cocaine. American Journal of Drug and Alcohol Abuse, 22, 561-

571.

Robins, L. N., & Przybeck, T. R. (1985). Age of onset of drug use as a factor in drug and

other disorders. In C. L. Jones & R. J. Battjes (Eds.), Etiology of Drug Abuse:

Implications for Prevention (NIDA Research Monograph No. 56, DHHS

Publication No. ADM 85-133) (pp. 178-192). Washington, DC: U.S. Government

Printing Office.

Roll, J. M., Prendergast, M., Richardson, K., Burdon, W., & Ramirez, A. (2005).

Identifying predictors of treatment outcome in a drug court program. American

Journal of Drug and Alcohol Abuse, 31(1), 73-90.

 87

Rounds-Bryant, P. L., Kristiansen, P. L., & Hubbard, R. L. (1999). Drug abuse treatment

outcome study of adolescents: A comparison of client characteristics and

pretreatment behaviors in three treatment modalities. American Journal of Drug

and Alcohol Abuse, 25(4), 593-591.

Rounsaville, B., Dollinsky, Z., Babor, T., & Meyer, R. (1987). Psychopathology as a

predictor of treatment outcome in alcoholics. Archives of General Psychiatry,

44(6) 505-513.

Ryan, R. M., Plant, R. W., & O’Malley, S. (1995). Initial motivations for alcohol

treatment: Relations with patient characteristics, treatment involvement, and

dropout. Addictive Behaviors, 20(3), 279-97.

SAMHSA, Substance Abuse & Mental Helath Services Administration, Office of

Applied Studies (2000). Summary of findings from the 1999 National Household

Survey on Drug Abuse. Rockville, MD. Retrieved December 15, 2005 from

http://www.drugabusestatistics.samhsa.gov

Savage, L., & Simpson, D. (1981). Drug use and crime during a four-year posttreatment

follow-up. American Journal of Drug and Alcohol Abuse, 8(1), 1-16.

Sears, C., Davis, T., & Guydish, J. (2002). Effects of treatment history and centralized

intake on drug treatment outcomes. Journal of Psychoactive Drugs, 34(1), 87-95.

 88

Sells, S. B., & Simpson, D. D. (1979). Evaluation of treatment outcome for youths in the

drug abuse reporting program (DARP): A follow-up study. In Beschner, G. M., &

Friedman, A. S., (Eds.), In Youth Drug Abuse (pp. 571-628). Lexington, MA:

Lexington Books.

Schade, A., Marquenie, L. A., Anton, J. L. M., Balkom, V., De Beurs, E., Van Dyck, R.,

et al. (2003). Do comorbid anxiety disorders in alcohol-dependent patients need

specific treatment to prevent relapse? Alcohol and Alcoholism: International

Journal of the Medical Council on Alcohol, 38(3), 255-262.

Schmitz, J. M., Stotts, A. L., Rothfleisch, J. M., Bailley, S. E., Sayre, S. L., & Grabowski,

J. (2000). Cocaine dependence with and without comorbid depression: A

comparison of patient characteristics. Drug and Alcohol Dependence, 60(2), 189-

98.

Schuckit, M.A. (1985). The clinical implications of primary diagnostic groups among

alcoholics. Archives of General Psychiatry, 42, 1043-1049.

Siguel, E. N., & Spillane, W. H. (1978). The effects of prior treatment on treatment

success. The International Journal of the Addictions, 13, 797-805.

Simpson, D. D. (1979). The relation of time spent in drug abuse treatment to post-

treatment outcome. American Journal of Psychiatry, 136, 1449-53.

 89

Simpson, D. D. (1983). National treatment system evaluation based on the drug abuse

reporting program (DARP) follow-up research. In F. M. Times & Ludford (Eds.),

Drug abuse treatment evaluation: Strategies, progress, and prospects (NIDA

Research Monograph, 51, (pp. 88-105). Rockville M. D: National Institute on

Drug Abuse.

Simpson, D. D. (1997). Program diversity and treatment retention rates in the drug abuse

treatment outcome study (DATOS). Psychological Addictive Behaviors, 11(4),

279-293.

Simpson, D. D., & Curry, S. J. (1997). Special issue: Drug abuse treatment outcome

study (DATOS). Psychology of Addictive Behaviors, 11(4). 27-31.

Simpson, D. D., & Joe, G. W. (1993). Motivation as predictor of early dropout from drug

abuse treatment. Special issue: Psychotherapy for the addictions. Psychotherapy,

30(2), 357-68.

Simpson, D. D., Joe, G. W., Fletcher, B. W., Hubbard, R., & Anglin, D. M. (1999). A

national evaluation of treatment outcomes for cocaine dependence. Archives of

General Psychiatry, 56, 507-514.

Staines, G., Magura, S., Rosenblum, A., Fong, C., Kosanke, N., Foote., J., & DeLuca, A.

(2003). Predictors of drinking outcomes in alcoholics. American Journal of Drug

and Alcohol Abuse, 29(1), 203-218.

 90

Stark, M. J. (1992). Dropping out of substance abuse treatment: A clinically oriented

view. Clinical Psychology Review, 12, 93-116.

Strecher, V. J., De Vellis, B. M., Becker, M. H., Rosenstock, L. M. (1986). The role of

self-efficacy in achieving health behavior change. Health Education Quarterly,

13, 73-91.

Swan, N. (1998). Drug abuse costs to society set at 97.7 billion, continuing steady

increase since 1975, Nida Notes, 13(4), November, 1998. Retrieved January 3,

2006, from

http://www.drugabuse.gov/NIDA_Notes/NNVol13N4/Abusecosts.html

Taylor, S. E., Kemeny, M. E., Bower, J. E., Gruenewald, T. L., & Reed, G. M. (2000).

Psychological resources, positive illusions, and health. American Psychologist,

55, 99-109.

Timko, C., & Moos, R. H. (2002). Symptom severity, amount of treatment, and 1-year

outcomes among dual diagnosis patients. Administration and Policy in Mental

Health, 30(1), 35-54.

Toumbourou, J. W., Hamilton, M., & Fallon, B. (1998). Treatment level progress and

time spent in treatment in the prediction of outcomes following drug-free

therapeutic community treatment. Addiction, 93(7), 1051-1064.

Vaillant, G. E. (1973). A 20-year follow-up of New York narcotic addicts. Archives of

General Psychiatry, 29(2), 237-241.

 91

Vaillant, G. E. (2000). The natural history of alcoholism: Revisited. Cambridge, MA:

Harvard University Press.

Walker, D., Donovan, D., Kivlahan, R., et al. (1983). Length of stay, neuropsychological

performance, and aftercare: Influences on alcohol treatment outcome. Journal of

Consulting and Clinical Psychology, 51(6), 900-911.

Ward, K. (2005). Is substance abuse treatment providing services to the right population?

Substance Use and Misuse, 40(3), 369-373.

Westermeyer, (1989). Nontreatment factors affecting treatment outcome in substance

abuse, American Journal of Drug and Alcohol Abuse, 15, 13-29.

Wexler, H. K., Falkin, G. P., & Lipton, D. S. (1990). Outcome evaluation of a prison

therapeutic community for substance abuse treatment. Criminal Justice and

Behavior, 17, 71-92.

Wexler, H. K., Melnick, G., Lowe, L., & Peters, J. (1999). 3-year incarceration outcomes

for amity in-prison therapeutic community and aftercare in California. The Prison

Journal, 79, 321-336.

White, A. M., Jordan, J. D., Schroeder, K. M., Acheson, S. K., Georgi, B. D., & Sauls,

G., et al.(2004). Predictors of relapse during treatment and treatment completion

among marijuana-dependent adolescents in an intensive outpatient substance

abuse program. Substance Abuse, 25, 53-59.

 92

Wu, P., Hoven, C. W., & Fuller, C. J. (2003). Factors associated with adolescents

receiving drug treatment: Findings from the national household survey on drug

abuse. The Journal of Behavioral Health Services & Research, 30(2), 190-201.

Young, D., & Belenko, S. (2002). Program retention and perceived coercion in three

models of mandatory drug treatment. Journal of Drug Issues, 32(1), 297-328.

Zanis, D. A., McLellan, T. A., & Corse, S. (1997). Is the addiction severity index a

reliable and valid assessment instrument among clients with severe and persistent

mental illness and substance abuse disorders? Community Mental Health Journal,

33(3), 213-227.
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APPENDIX

A. COPY OF INFORMED CONSENT

INFORMED CONSENT

Meeting Date: August 5, 2003

FOR QUESTIONS ABOUT THE STUDY, CONTACT: Keith Harris, Ph.D., Health

Science Specialist, Domiciliary Services, 795 Willow Road, Menlo Park, CA 94025, 650-

493-5000 x23163.

Are you participating in any other research studies? _____yes _____no

DESCRIPTION: You are invited to participate in a research study in which we will be

examining the experiences of former residents of the Homeless Veterans Rehabilitation

Program. You will be asked to complete a brief questionnaire on housing, employment

and substance use approximately every three months. It will take no more than 2 minutes

to complete the questionnaire. Your responses will be seen only by the research team and

will not be available to the treatment team until the data have been pooled. We hope to

learn more about the effectiveness of the program as well as to identify possible

improvements; thus you are encouraged to answer honestly and completely. You have

been selected as a possible participant in this study because you are a resident of the

Homeless Veterans Rehabilitation Program (HVRP). We hope to enroll 1,000

individuals in the entire study, and we anticipate that approximately 750 of these

individuals will complete the questionnaire on-site at HVRP.

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Your participation in this study is entirely voluntary. Your decision whether or not to

participate will not prejudice you or your medical care. If you wish to participate in this

study, you must sign this form. If you decide to participate, you are free to withdraw

your consent, including your authorization regarding the use and disclosure of your

health information, and to discontinue participation at any time without prejudice to you

or effect on your medical care. If you decide to terminate your participation in this study,

you should notify Dr. Keith Harris at 650-493-5000 x 23163.

If you decide to participate, we will ask you to complete a questionnaire, which will take

less than 2 minutes approximately every 3 months. There are no direct benefits to you

from participating in this study; however, your participation will contribute to making

this a better program for future residents. WE CANNOT AND DO NOT GUARANTEE

OR PROMISE THAT YOU WILL RECEIVE ANY BENEFITS FROM THIS STUDY.

You will be told if any new information is learned which may affect your condition or

influence your willingness to continue participation in this study.

This study does not include any treatment, and no treatment is being withheld. The

alternative is not to participate.

Any data that may be published in scientific journals will not reveal the identity of the

subjects. Patient information may be provided to Federal and regulatory agencies as

required. The Food and Drug Administration, for example, may inspect research records

and learn your identity if this study falls within its jurisdiction. The responses to questions
 95

concerning illegal drug use could be self-incriminating and harmful to you if they became

known outside the study. However, as explained in the confidentiality statement below, we

do not intend to disclose this information.

No payment will be provided for participation in this project. There will be no cost to you

to participate.

The Veterans Administration Palo Alto Health Care System is providing the

materials and staff for this study.

At the discretion of the protocol director subjects may be taken out of this study due to

unanticipated circumstances.

Some possible reasons for withdrawing a subject from the study include: failure to follow

instructions, the study is cancelled, or other administrative reasons.

If you have any questions, we expect you to ask us. If you have any additional questions

later, Dr. Keith Harris at 650-493-5000 ext. 23163 will be happy to answer them.

USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION: By signing this

form, you are authorizing the use and disclosure of your health information collected in

connection with your participation in this research study. Your information will only be

used in accordance with the provisions of this consent form and applicable law. If you

decide to terminate your participation in the study, or if you are removed from the study

by the protocol director, you may revoke your authorization, except to the extent that the

law allows us to continue using your information. Information that may be used or
 96

disclosed includes health information related to this study, including, but not limited to,

housing, employment, and substance use, date of discharge from the program, discharge

status, and length of stay. The following parties are authorized to use and/or disclose

your health information in connection with this research study: Keith Harris, Ph.D., The

Stanford University Administrative Panel on Human Subjects in Non-medical Research,

and the research team working on this study. These parties may disclose your health

information to the following organization for their use in connection with this research

study: The Office for Human Research Protections in the U. S. Department of Health

and Human Services. Your information may be re-disclosed if the recipients described

above are not required by law to protect the privacy of the information.

EXPIRATION: Your authorization for the use and/or disclosure of your health

information will expire upon completion of the research study.

WHEN ACCESS TO YOUR INFORMATION MAY BE LIMITED: You may not

be allowed to see or copy certain information in your medical records collected in

connection with your participation in this research study while the research is in progress.

Should you be injured as a result of participation in this research project which has been

approved by a VA Research and Development Committee and conducted under the

supervision of one or more VA employees, VA will provide you free medical care for

those injuries pursuant to 38 C.F.R. 17.85. This section applies to both Veteran and non-

veteran research subjects. You will not be afforded medical care for: (1) treatment for

injuries due to noncompliance by you with study procedures, or (2) research conducted

for VA under a contract with an individual or a non-VA institution.

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If you are a Veteran, 38 U.S.C.A. § 1151, may provide you with dependency and

indemnity compensation for a qualifying additional disability or a qualifying death in the

same manner as if such additional disability or death were service-connected. A

disability or death is a qualifying additional disability or qualifying death if the disability

or death was not the result of your willful misconduct and was caused by hospital care,

medical or surgical treatment, or examination furnished to you and the proximate cause

of the disability or death was either; (a) carelessness, negligence, lack of proper skill,

error in judgment, or similar instance of fault on the part of the Department in furnishing

the hospital care, medical or surgical treatment, or examination; or (b) an event not

reasonably foreseeable. For further information, contact the V.A. Regional Counsel at

(415) 750-2288.

You do not waive any liability rights for personal injury by signing this form. If you feel

that the above remedies for your injuries are not sufficient, and irrespective of your status

as a Veteran or a non-veteran, the Federal Tort Claims Act, 28 U.S.C. §§ 1346(b) and

2671-2680, may provide an additional remedy if the VA is at fault for your injuries.

For further information, please call (650) 723-5244 or write the Administrative Panel on

Human Subjects in Medical Research, Administrative Panels Office, Stanford University,

Stanford, CA 94305-5401. In addition, if you are not satisfied with the manner in which

this study is being conducted or if you have any questions concerning your rights as a

study participant, please contact the Human Subjects Office at the same address and

telephone number.

BILL OF RIGHTS
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As a human subject you have the following rights. These rights include but are not limited to the subject's right to:

۰ be informed of the nature and purpose of the experiment;

۰ be given an explanation of the procedures to be followed in the medical

experiment, and any drug or device to be utilized;

۰ be given a description of any attendant discomforts and risks reasonably to be

expected;

۰ be given an explanation of any benefits to the subject reasonably to be

expected, if applicable;

۰ be given a disclosure of any appropriate alternatives, drugs or devices that might

be advantageous to the subject, their relative risks and benefits;

۰ be informed of the avenues of medical treatment, if any available to the subject

after the experiment if complications should rise;

۰ be given an opportunity to ask questions concerning the experiment or the

procedures involved;

۰ be instructed that consent to participate in the medical experiment may be

withdrawn at any time and the subject may discontinue participation without

prejudice;

۰ be given a copy of the signed and dated consent form;

۰ and be given the opportunity to decide to consent or not to consent to a medical

experiment without the intervention of any element of force, fraud, deceit,

duress, coercion or undue influence on the subject's decision.

YOUR SIGNATURE INDICATES THAT YOU HAVE READ AND UNDERSTAND

THE ABOVE INFORMATION, THAT YOU HAVE DISCUSSED THIS STUDY

WITH THE PERSON OBTAINING CONSENT, THAT YOU HAVE DECIDED TO

PARTICIPATE BASED ON THE INFORMATION PROVIDED, AND THAT A

COPY OF THIS FORM HAS BEEN GIVEN TO YOU.

SUBJECT’S RIGHTS: If you have read this form and have decided to participate in

this study, please understand that your participation is voluntary and you have the right to

withdraw your consent or discontinue participation at any time without penalty. You
 99

have the right to refuse to answer particular questions. Your individual privacy will be

maintained in all published and written data resulting from this study. If you have any

questions about your rights as a study participant, or are dissatisfied with any aspect of

this study, you may contact - anonymously if you wish - the Administrative Panels

Office, Stanford University, Stanford, CA (USA) 93405-5401, Phone (650) 723-5244

(you may call collect). The extra copy of this consent form is for you to keep.

________________________________ ___________________

Signature of Participant Date

________________________________ ___________________

Signature of Person Obtaining Consent Date

Approval Date: ___8/5/03_________________ Expiration Date:

___8/4/04_______________
100
 101

APPENDIX

B. DOMICILIARY FOLLOW-UP QUESTIONNAIRE

Domiciliary Follow-Up Questionnaire

Today’s Date____________________

We are asking your help in evaluating and improving the Homeless Veterans

Rehabilitation Program. Please answer all the questions honestly. This questionnaire is

not a test and your answers will not be given to the treatment team.

Thank you for your help.

(check one)

1. Have you used alcohol or any non-prescribed drugs since your Yes No
discharge from the Domiciliary?

If yes, how many months after your discharge did you first use?
___ MONTH

If less than one month, how many days after discharge did you _ S

first use? or

___ DAYS

_
 102

2. Have you used alcohol or any non-prescribed drugs in the past 3 Yes No

months?

3. Have you been homeless (staying outdoors, in a vehicle, abandoned

Yes No
building, emergency shelter – not counting Irvin’s) for one week or

more since your discharge from the Domiciliary?

If yes, how many months after discharge did you first become
___ MONTH
homeless?
_ S
If less than one month, how many days after discharge did you
or
first become homeless?
___ DAYS

4. Have you been homeless (staying outdoors, in a vehicle, abandoned

Yes No
building, emergency shelter – not counting Irvin’s) for one week or

more during the past 3 months?

5. Have you been unemployed for one month or more since your Yes No

discharge from the Domiciliary?

If yes, how many months after discharge did you first become

unemployed ___ MONTH

_ S

6. Have you been unemployed for one month or more during the past Yes No

3 months?
103