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 posttreatment outcomes?

© Copyright 2006 by Lawrence Ferber All Rights Reserved

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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

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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 pretreatment 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.

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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

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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

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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

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LIST OF TABLES Table 1 2 3 Page Sociodemographic Characteristics (N=136)..............................................................39 Descriptive Statistics for Primary Study Variables....................................................43 Testing Primary Hypotheses (N=136)........................................................................51

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LIST OF FIGURES Figure 1 2 Page

Figure 1. Global Assessment of Functioning (GAF) - graduate status......................46 Figure 240. How long with drug and alcohol problems-graduate status...................50

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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) LongTerm 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 3month 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 dayhospital 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 biopsycho-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 cooccurring 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-tocustody (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 posttreatment 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 cooccurrence 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 selfefficacy 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 followup 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, comorbid 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-healthoriented 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 noncompleters. 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 noncompleters. 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 noncompleters. 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 paperand-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 21item 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 Mean Age Gender Male Female Marital status Married Single Separated Divorced Ethnicity African American Caucasian Hispanic Other Non-completers 48.8 47 1 2 16 6 24 Completers Graduates 48.5 53 1 4 17 4 29 46.7 32 2 2 15 0 17 n 136 132 4 .733 8 48 10 70 .521 22 23 3 0 24 27 2 2 16 12 3 2 62 62 8 4 F 1.048 .502 χ2

(table continues) Table 1 (continued) Variable Religion Catholic Christian Protestant Other None Education < High school High school or 5 39 5 38 2 29 12 106 5 26 4 3 10 8 31 2 1 11 9 18 3 0 5 22 75 9 4 26 .529 Non-completers Completers Graduates n F χ2 .729

40 GED AA degree BA/BS degree Graduate work 2 1 0 7 3 1 3 0 1 12 4 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 noncompleters (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 noncompleters’. 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 noncompleters 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 Years 15 10 5 0 Noncompleters Completers Completion Status Graduates

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

51 Table 3 Testing Primary Hypotheses (N=136) Variable BDI-II Employmenta Age of Onsetb No. of past hospitalizations 61.6 GAF scoresc Jail timed No. of arrests No. of drug and alcohol programs No. of medical issues No. of years addicted Agee 10.7 8.2 2.1 5.04 22.5 48.8 70.2 5.1 5 2 5.13 16.6 48.5 70.3 11.6 9.3 2.2 4.47 8.8 48.7 35.60 * 2.570 1.440 0.087 1.170 6.780 * 0.502 (table continues) Table 3 (continued) Variable Gender 47 Male Female Ethnicity African 1 53 1 32 2 13 2 4 . 521 22 24 16 62 Non-Completer Completer Graduate n F χ2 .502 Non-Completer 13.9 6.86 14.7 0.75 Completer 13.2 6.27 14.1 0.56 Graduate 13 5.58 13.6 0.35 n F 0.133 0.465 1.050 0.417 χ2

52 American Caucasian Hispanic Other Marital status Divorced Married Separated Single Religion Catholic Christian Table 3 (continued) Variable Religion
(continued)

22 3 0

27 2 1

12 3 4

61 8 5

. . 733

24 2 6 16

29 4 4 17

17 2 0 15

70 8 10 48 . 729

5 26

8 29

9 17

22 72 (table continues) n F χ2

Non-Completer

Completer

Graduate

4 3 10

2 1 11

3 0 5

9 4 26 .

Protestant Other None specified

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 comorbid 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 pretreatment 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 nonsignificant. 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.

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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.

93 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, 650493-5000 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.

94 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 nonveteran 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.

97 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

98
As a human subject you have the following rights. These rights include but are not limited to the subject's right to:

۰ ۰

be informed of the nature and purpose of the experiment; 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 ۰

be given a copy of the signed and dated consent form; 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 discharge from the Domiciliary? If yes, how many months after your discharge did you first use? ___ If less than one month, how many days after discharge did you first use? ___ _ _ MONTH S or DAYS Yes No

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2. Have you used alcohol or any non-prescribed drugs in the past 3 months?

Yes

No

3. Have you been homeless (staying outdoors, in a vehicle, abandoned 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

Yes

No

___ homeless? _ If less than one month, how many days after discharge did you first become homeless? ___ _ 4. Have you been homeless (staying outdoors, in a vehicle, abandoned 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 discharge from the Domiciliary? If yes, how many months after discharge did you first become unemployed ___ _ 6. Have you been unemployed for one month or more during the past 3 months? Yes Yes Yes

MONTH S or DAYS

No

No

MONTH S No

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