Professional Documents
Culture Documents
A Dissertation
Lawrence Ferber
demographics (i.e., race, age, marital status and ethnicity), employment status, level of
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
ii
ARE POST-TREATMENT DIFFERENCES A FUNCTION OF PRE-TREATMENT
CHARACTERISTICS IN NON-COMPLETERS, COMPLETERS, AND GRADUATES
OF THE HOMELESS VETERANS REHABILITATION PROGRAM?
committee has been accepted and approved by the Faculty of Pacific Graduate School of
DOCTOR OF PHILOSOPHY
IN PSYCHOLOGY
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
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-
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
Treatment Duration.......................................................................................................11
Treatment Completion..................................................................................................16
Demographics ..........................................................................................................19
Psychiatric Co-Morbidity.........................................................................................24
Age of Onset............................................................................................................28
Strengths...................................................................................................................31
Weaknesses .............................................................................................................31
Proposed Study.............................................................................................................33
Participants....................................................................................................................36
Procedures.....................................................................................................................36
Measures ......................................................................................................................37
v
Depressive Symptoms..............................................................................................37
Analyses .......................................................................................................................38
Non-Significant Findings..............................................................................................55
Employment Status..................................................................................................56
Marital Status...........................................................................................................57
vi
Age of Onset.............................................................................................................60
Limitations....................................................................................................................63
Clinical Implications.....................................................................................................64
Future Directions...........................................................................................................65
Summary.......................................................................................................................66
vii
LIST OF TABLES
Table Page
viii
LIST OF FIGURES
Figure Page
2 Figure 240. How long with drug and alcohol problems-graduate status...................50
ix
1
CHAPTER
I. INTRODUCTION
-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
Health Care System was the first domiciliary in the nation to combine the components of
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
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
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
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
Given the apparent link between program retention and long-term outcome
program completion. It is possible that the results of this recent study were accounted for
with regard to characteristics such as demographics (gender, race, and age), employment
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.
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
substance abuse treatment could facilitate refinement of clinical interventions that could
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
al., 2004), there is an increased acceptance of the importance of treating both disorders
abuse treatment, it would suggest the necessity of integrative approaches that target mood
Focus
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
CHAPTER
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
alcohol and/or illegal drugs (SAMHSA, 2000). Alcohol use disorders were estimated in
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,
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
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
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
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).
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
beneficial for drug abusers identified in jails or prisons, and it can play a central role in
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).
every dollar spent on treatment there was a $7 savings due to reduced criminal activity
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
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).
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
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).
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
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
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
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
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
To address this problem, some have emphasized the importance of using classical
While such small scale, single-modality trials, or “efficacy trials,” can determine the
therapeutic factors that contribute to the observed outcomes (Kaminer, 2001), only
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
Treatment Duration
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
reasons. Across a large number of studies, treatment duration and completion have been
negatively related to continued use whether the associations were measured concurrently
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
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
(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).
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
facility operated by the Federal Bureau of Prisons. The program is based on the bio-
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
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
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
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
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
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
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).
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
(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
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
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
custody (RTC), with 4,155 inmates that chose to participate in prison-based therapeutic
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
Treatment Completion
treatment programs (Rabinowitz & Marjefsky, 1998). Thus, understanding links between
substance abuse patients. In DATOS (Anglin et al., 1997; Caplehorn et al., 1998), in the
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
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%,
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
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
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
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
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
treatment outcome (Brewer et al., 1998). There is a need for researchers to continue
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
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
literature may very well be due to the different number of treatment methods that were
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,
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,
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
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
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
(Platt, 1995). Additionally, work becomes the primary vehicle for reintegrating the
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
The relationship between substance abuse and crime has been documented and
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
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
the patients in outpatient substance abuse treatment, and one-quarter of the patients in
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
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
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
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,
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
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
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
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
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
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
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
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
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
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).
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
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
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
(Johnson et al., 1998). The earlier a child begins the use of alcohol and drugs, the greater
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
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).
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).
psychological approach to the treatment of drug and alcohol abuse (De Leon, 1994).
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
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
correctional facilities (Wexler, Falkin, & Lipton, 1990). The TC model has been the best
(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
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
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
outcome. However, little is known about factors that impact retention in TC’s.
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
A survival analysis was used to determine months after discharge until substance
survival analysis was also conducted, where success rates were compared for program
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
with subsequent outcomes, it is unclear whether these differences across the 3 groups are
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
Proposed Study
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,
that:
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
5. Graduates and completers would have had more jobs in the 10 years prior to
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
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
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
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
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
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
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
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-
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
Measures
Depressive Symptoms
The Beck Depression Inventory-II (BDI) (Beck, Steer, & Garbin, 1988) is a 21-
Respondents select from 1 to 4 severity options for each symptom and it takes about 10
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
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
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
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)
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
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
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
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
depression at baseline than non-completers, and graduates would have lower baseline
We hypothesized that graduates and completers would have higher GAF scores
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
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
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.
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
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-
education than did non-completers. This was not the case, F(20, 135) =.366, ns.
48
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
backgrounds. We found this to be the case (see Table 1). There were no significant
We hypothesized that graduates and completers would have had fewer prior
incarcerations than non-completers, and graduates would have fewer incarcerations than
individuals had been arrested, and the actual time served, as measured by the mean
F(2,127)=.240, ns, nor time served, F(2, 132)= .080, ns, were significant.
married than non-completers’. This was not the case. Thus, our hypothesis was not
completers would be. Using an ANOVA we did not find evidence of significant
than non-completers’ upon admission to the program. We did not find this to be the case,
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
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)
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 .
.
Religion 729
Catholic 5 8 9 22
Christian 26 29 17 72
(table continues)
Table 3 (continued)
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
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,
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
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
together, these findings suggest that lower functioning patients may have a more difficult
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
Non-Significant Findings
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
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
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
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
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
(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
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
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
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
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
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
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
(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
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
Age of Onset
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
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
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
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
1997).
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
have also noted that there was a small but significant correlation between patient
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
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
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
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
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-
does not predict treatment completion/graduation (e.g., fixed conditions such as race, age,
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
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
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
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
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
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
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
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APPENDIX
INFORMED CONSENT
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.
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
individuals in the entire study, and we anticipate that approximately 750 of these
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,
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
This study does not include any treatment, and no treatment is being withheld. The
Any data that may be published in scientific journals will not reveal the identity of the
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
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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
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
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
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.
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
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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
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
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
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
If you are a Veteran, 38 U.S.C.A. § 1151, may provide you with dependency and
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
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:
expected;
expected, if applicable;
procedures involved;
withdrawn at any time and the subject may discontinue participation without
prejudice;
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
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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
(you may call collect). The extra copy of this consent form is for you to keep.
________________________________ ___________________
________________________________ ___________________
___8/4/04_______________
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APPENDIX
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.
(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
_
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2. Have you used alcohol or any non-prescribed drugs in the past 3 Yes No
months?
5. Have you been unemployed for one month or more since your Yes No
If yes, how many months after discharge did you first become
_ S
6. Have you been unemployed for one month or more during the past Yes No
3 months?
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