Beyond the Therapeutic Alliance:
Keeping the Drug-Dependent
Individual in Treatment
Editors:
Lisa Simon Onken, Ph.D.
Jack D. Blaine, M.D.
John J. Boren, Ph.D.
NIDA Research Monograph 165
1997
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
National Institute on Drug Abuse
Division of Clinical and Services Research
5600 Fishers Lane
Rockville, MD 20857
ACKNOWLEDGMENT
This monograph is based on the papers from a
technical review on " Beyond the Therapeutic Alliance:
Keeping the Drug-Dependent Individual in Treatment"
held on May 10-11, 1994. The review meeting was
sponsored by the National Institute on Drug Abuse.
COPYRIGHT STATUS
The National Institute on Drug Abuse has obtained
permission from the copyright holders to reproduce
certain previously published material as noted in the
text. Further reproduction of this copyrighted material is
permitted only as part of a reprinting of the entire
publication or chapter. For any other use, the copyright
holder's permission is required. All other material in this
volume except quoted passages from copyrighted sources
is in the public domain and may be used or reproduced
without permission from the Institute or the authors.
Citation of the source is appreciated.
Opinions expressed in this volume are those of the
authors and do not necessarily reflect the opinions or
official policy of the National Institute on Drug Abuse or
any other part of the U.S. Department of Health and
Human Services.
The U.S. Government does not endorse or favor any
specific commercial product or company. Trade,
proprietary, or company names appearing in this
publication are used only because they are considered
essential in the context of the studies reported herein.
National Institute on Drug Abuse
NIH Publication No. 97-4142
Printed May 1997
NIDA Research Monographs are indexed in the Index Medicus. They are
selectively included in the coverage of American Statistics Index,
BioSciences Information Service, Chemical Abstracts, Current Contents,
Psychological Abstracts, and Psychopharmacology Abstracts.
ii
Table of Contents
Treatment for Drug Addiction: It Won’t Work If
They Don’t Receive It......................................................................1
Lisa Simon Onken, Jack D. Blaine, and John J. Boren
Enhancing Retention in Clinical Trials of Psychosocial
Treatments: Practical Strategies........................................................4
Kathleen M. Carroll
From the Initial Clinic Contact to Aftercare: A Brief
Review of Effective Strategies for Retaining Cocaine
Abusers in Treatment......................................................................25
Stephen T. Higgins and Alan J. Budney
Help-Seeking by Substance Abusers: The Role of Harm
Reduction and Behavioral-Economic Approaches To Facilitate
Treatment Entry and Retention......................................................44
G. Alan Marlatt, Jalie A. Tucker, Dennis M. Donovan,
and Rudy E. Vuchinich
Tailoring Interventions to Clients: Effects on Engagement
and Retention..................................................................................85
Larry E. Beutler, Heidi Zetzer, and Elizabeth Yost
Factors Associated With Treatment Continuation:
Implications for the Treatment of Drug Dependence.....................110
Gregory G. Kolden, Kenneth I. Howard, Elizabeth A. Bankoff,
Michael S. Maling, and Zoran Martinovich
Stages of Change: Interactions With Treatment Compliance
and Involvement...........................................................................131
Carlo C. DiClemente and Carl W. Scott
The Role of Family and Significant Others in the
Engagement and Retention of Drug-Dependent Individuals............157
M. Duncan Stanton
Establishing and Maintaining a Therapeutic Alliance With Substance
Abuse Patients: A Cognitive Therapy Approach............................181
Cory F. Newman
iii
Back to Basics: Fundamental Cognitive Therapy Skills for
Keeping Drug-Dependent Individuals in Treatment........................207
Bruce S. Liese and Aaron T. Beck
Establishing a Therapeutic Alliance With Substance
Abusers..........................................................................................233
Lester Luborsky, Jacques P. Barber, Lynne Siqueland,
A. Thomas McLellan, and George Woody
iv
Treatment for Drug Addiction:
It Won’t Work If They Don’t Receive
It
Lisa Simon Onken, Jack D. Blaine, and John J. Boren
Treatment won’t work if it is not administered. Penicillin will not
effectively treat streptococcal pneumonia if patients don’t take it,
and take it as prescribed. Insulin won’t help a diabetic if it is not used.
Cognitive therapy for panic disorder won’t work if all the therapy
sessions are missed. And treatment for drug addiction will not work if
the addict is not engaged and retained in treatment. Although
engagement, retention, and compliance are problems for the
treatment of virtually every medical and mental disorder, these issues
are especially problematic for drug addiction treatment.
People want bacterial infections to go away. They want to be free of
the symptoms of diabetes. They want the panic attacks to stop.
However, drug addiction is a disorder that many individuals do not
necessarily want to stop. Unlike most medical and mental disorders,
drug addiction has a strong component. If the pleasure associated
with drug taking did not create so many social, financial, criminal, and
medical problems, it is hard to imagine many people seeking
treatment at all. Thus, while drug-addicted individuals want to stop
the problems associated with drug use, they may not want to stop
taking drugs.
Some want treatment, but the very thing for which they are seeking
treatment can prevent them from coming—that is, they are involved
in drug-taking behavior, making them unavailable for treatment. And
for some, problems associated with drug addiction (e.g., medical
problems, low income, lack of adequate transportation, inability to
pay for child care) make it difficult to engage in treatment.
These and other factors contribute to a person’s inclination and
ability to change and readiness to engage in a particular type of
treatment. One of the more exciting concepts put forth in the drug
addiction treat-ment research field is Prochaska and associates’
(1992) Stages of Change model, promoting the idea that people cycle
through varying degrees of readiness for change and that treatments
1
should be tailored to meet the individual’s readiness level, rather than
imposing an inappropriate treatment on the individual.
In drug addiction treatment research, the issue of patient dropout is
always present. Sometimes, it is merely acknowledged. Oftentimes,
while it is acknowledged that statistical correction is inadequate, in the
absence of alternatives, statistical corrections are nonetheless made.
Most investigators do the best they can to retain patients in
treatment, and then analyze their data with all of its flaws. A clinical
trial of a drug addiction treatment without the problems created by
dropout is, at this point, a fantasy.
It was because of the enormity of the problem of patient dropout that
a meeting was held to address the issues of engagement and retention
in drug addiction treatment. The name of the meeting, "Beyond the
Therapeutic Alliance: Keeping the Drug-Dependent Individual in
Treatment" was chosen because of the belief of the cochairs that far
more was needed than a strong therapeutic alliance to engage and
retain drug-addicted individuals in treatment. The purpose of the
meeting was to review the literature on research in this area, but, even
more important, to stimulate new research that addresses directly the
issues of the engagement and retention of drug-addicted individuals in
treatment. The meeting was held on May 10 and 11, 1994, and was
chaired by Lisa Simon Onken, Ph.D., Jack Blaine, M.D., and John
Boren, Ph.D., of the National Institute on Drug Abuse’s Treatment
Research Branch. Participants included Larry Beutler, Ph.D.,
Kathleen Carroll, Ph.D., Carlo DiClemente, Ph.D., Ellen Frank,
Ph.D., Stephen T. Higgins, Ph.D., Kenneth I. Howard, Ph.D., Bruce
Liese, Ph.D., Lester Luborsky, Ph.D., G. Alan Marlatt, Ph.D., A.
Thomas McLellan, Ph.D., Cory Newman, Ph.D., and M. Duncan
Stanton, Ph.D. The chapters that follow are the product of this
meeting.
REFERENCES
Prochaska, J.O.; DiClemente, C.C.; and Norcross, J.C. In search of how
people change: Applications to addictive behaviors. Am
Psychol 47:1102-1114, 1992.
2
AUTHORS
Lisa Simon Onken, Ph.D.
Associate Chief
Treatment Research Branch
Jack D. Blaine, M.D.
Chief
Treatment Research Branch
John J. Boren, Ph.D.
Research Psychologist
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
Parklawn Building, Room 10A-30
5600 Fishers Lane
Rockville, MD 20857
3
Enhancing Retention in Clinical Trials
of Psychosocial Treatments:
Practical Strategies
Kathleen M. Carroll
There is increasing awareness, from both clinical and research
perspectives, of the substantial methodological and statistical
problems associated with the typically high rates of attrition in
clinical trials (Howard et al. 1990; Kalton 1983; Lackin and Foulkes
1986; Lavori 1992). These issues are particularly critical for trials
involving substance abusers (Howard et al. 1990; Sparr et al. 1993),
where rates of attrition often range from 25 to 90 percent (Baekeland
and Lundwall 1975; DeLeon 1991; Wickizer et al. 1994).
Traditionally, attrition has been conceived as patient driven; that is,
investigators have focused their efforts on searching for patient
characteristics associated with poor retention, such as demographic
characteristics, social instability, and low motivation (e.g., Agosti et
al. 1991; Babst et al. 1971; Baekeland and Lundwall 1975; Swett and
Noones 1989; Szapocznik and Ladner 1977).
That perspective is now shifting, and current efforts to reduce
attrition in clinical trials reflect increasing awareness that retention
reflects a combination of conditions and efforts contributed by
therapists, investigators, and research staff, in addition to patients
(DeLeon 1991; DiClemente 1993). This chapter describes practical
strategies for retaining substance-abusing patients in clinical trials,
particularly studies evaluating psychosocial treatments. Examples are
drawn from the series of trials evaluating psychotherapies and
pharmacotherapies for cocaine abusers at Yale (Carroll et al. 1991,
1994c), as well as the National Institute on Alcoholism and Alcohol
Abuse (NIAAA)-funded Project MATCH (Project MATCH Research
Group 1993), a multisite collaborative clinical trial evaluating patient
treatment matching in alcoholics. In these studies, which evaluated
manual-guided psychotherapeutic approaches in outpatient settings
with a variety of substance-abusing populations, retention was given
close attention because of the need for adequate statistical power, the
need to expose patients to an adequate dose of study treatments, the
need to retain a study sample that reflected the larger population
from which it was drawn, and the need to avoid statistical problems
associated with differential attrition. Thus, the author’s research
team used a number of strategies intended to enhance retention. Use
4
of these strategies reflects three assumptions about retention:
retention reflects a good fit between patient, setting, provider and
treatment; attrition typically occurs early in treatment; and retention
is an outcome.
RETENTION REFLECTS GOOD FIT
In both clinical and research settings, patient heterogeneity has
usually been met with treatment homogeneity. That is, regardless of
patients’ background and preferences, the nature or severity of their
substance abuse and related problems, or the factors that precipitated
seeking treatment, many treatment programs offer only a single type
of treatment (which is usually poorly defined as to content, goals,
approach, treatment provider, and duration). With this one-size-fitsall model, variations in retention and outcome have traditionally been
ascribed to patient factors and characteristics (e.g., Agosti et al. 1991;
Keil and Esters 1982; Swett and Noones 1989; Szapocznik and Ladner
1977). Thus, patients who are a good fit for a given approach are
more likely to remain in treatment, and those who are less well suited
are more likely to drop out.
Given this approach, the search for universal patient characteristics
associated with retention has been no more successful than the search
for the alcoholic personality, as patient characteristics associated with
dropout in one treatment setting are usually not replicated in another
setting with a vastly different treatment approach. A more recent,
and potentially more fruitful, approach to evaluating retention is
recognition that retention may have more to do with what
investigators and treatment providers do than who the patients are.
For example, Herceg-Baron and colleagues (1979) found that attrition
patterns varied as a function of the type of treatment
(pharmacotherapy or psychotherapy) patients received in a study of
treatments for depression.
ATTRITION OCCURS EARLY
While there is little consistency across studies and treatment settings
in terms of characteristics of patients who drop out of treatment,
there is a good deal of consistency across studies suggesting that most
attrition occurs early, with the majority of dropouts usually occurring
during the first month of treatment (Baekeland and Lundwall 1975;
DeLeon 1991; Silberfeld and Glaser 1978; Swett and Noones 1989).
5
Again, in treatment settings that offer only a single approach, it may
not make sense to ask the patient what he or she needs, desires, or
expects out of treatment, as if the patient wants something other
than what the center provides; very often, there is little that staff can
do. Moreover, treatment staff are often so vague in explaining to the
patient what to expect in treatment that the patient typically has
only an uncertain idea of what treatment will actually consist of until
it begins. Thus, early attrition may reflect self-selection, where
patients may find themselves in the wrong treatment setting, wrong
group, with the wrong therapist, participating in a treatment geared to
a stage other than the one they are in. It is thus not surprising that
dropouts usually seek treatment again elsewhere (Peterson et al.
1994).
RETENTION IS AN OUTCOME
In substance abuse treatment, retention is more or less the outcome.
Better retention tends to be associated with better outcomes in terms
of reductions in substance abuse (Simpson and Sells 1982).
Furthermore, the treatments for substance abuse are considered
effective to the extent they demonstrate the ability to retain
patients. Methadone maintenance, despite its drawbacks, is the most
successful pharmacologic strategy for opioid dependence, in large part
because of its power to retain patients over extended periods. On the
other hand, naltrexone, which is an elegant, safe, long-acting, and
theoretically perfect treatment, is infrequently used and often
perceived as ineffective largely because of its poor track record of
retention. Similarly, the combined voucher and community
reinforcement approach (CRA) approach described by Higgins and
colleagues (this volume) has generated a great deal of excitement
because several trials evaluating this approach have shown high
retention and abstinence rates among cocaine abusers.
To the extent that potent treatments can be developed that are
responsive to patients’ needs, it is likely that treatment retention,
compliance, and outcome will be improved. Moreover, procedures
and strategies that have been found to improve treatment compliance
and retention in clinical areas other than substance abuse
(Meichenbaum and Turk 1987) are likely to be applicable and
effective in improving treatment retention among substance abusers
as well.
6
STRATEGIES RELATED TO PATIENTS
Some, but clearly not all, variation in retention in clinical trials may
have to do with the types of patients included in different trials.
Because different types of patients may respond to different
treatments, sample heterogeneity versus homogeneity may be one
determinant of attrition patterns within a trial. The appropriate level
of sample heterogeneity in a trial depends on its aims and goals. For
example, in small, tightly controlled efficacy studies in which
investigators attempt to attribute all variation in outcome to
treatments evaluated (explanatory trials), variability in other factors,
including patients, should be held to a minimum (Sackett and Gent
1979). Conversely, in a generalizability study, which evaluates the
effectiveness of the study treatment in the broader population of
individuals with the disorder, a more heterogeneous population would
be desirable.
Restrict Sample Variability
One means of avoiding attrition in clinical trials is to narrow inclusion
and exclusion criteria to patients who are likely to comply with,
remain in, and benefit from study treatments. Thus such a study
might exclude patients with high psychopathology, those who do not
have stable social supports, those who live far from the treatment
site, and those who are not motivated for treatment. With this type
of strategy, however, the study sample is likely to be highly select and
may have little resemblance to the larger population from which it
was drawn. For example, in the Veterans Administration’s (VA)
Cooperative Disulfiram Study, the relatively restrictive set of
inclusion-exclusion criteria used yielded only 600 subjects from a
potential pool of over 6,000 (Fuller et al. 1986).
The effects of restricted sample variability on retention and outcome
may be also illustrated by the series of studies evaluating the
effectiveness of desipramine treatment of cocaine dependence. An
early trial, led by Gawin and colleagues at Yale (1989), suggested the
effectiveness of desipramine over lithium and placebo for retention
and other outcomes, using a sample that was composed primarily of
white, employed, intranasal users with comparatively low levels of
psychopathology. Later desipramine trials, which included more
heterogeneous samples that varied across several dimensions (e.g.,
race, severity, route of administration, and level of
psychopathology), generally failed to find a desipramine effect on
retention or cocaine use, or found an effect only for subsamples with
7
lower severity cocaine use (Carroll et al. 1994c) or for subjects
without antisocial personality disorder (Arndt et al. 1994).
Increase Difficulty of Treatment Entry
Another method for reducing attrition is to make it more difficult for
substance abusers to enter treatment in the first place. While not
necessarily always conceived as such, many methadone programs
routinely make use of this strategy. That is, treatment applicants are
placed on waiting lists of up to 6 months and are asked to call every 2
weeks to confirm their interest in treatment or place on the waiting
list, and patients who fail to call are dropped from the list. Thus,
individuals who persist with contacting the clinic over an extended
period of time, or survive the waiting list, may be more motivated or
stable and hence more likely to remain in treatment once admitted.
Similarly, Craig (1985) described a set of procedures that reduced the
rate of dropouts from an inpatient substance abuse treatment program
from 70 to 20 percent. These procedures included requiring a 2-day
preadmission evaluation or completion of a 30- to 60-day outpatient
program prior to inpatient admission for patients who had histories of
negative behavior. Once admitted, patients completed treatment
contracts, and were required to meet with their group before leaving
against medical advice (AMA). In addition, the program offered the
availability of a counselor during evenings and weekends when the
majority of AMA discharges tended to occur.
An example of this type of approach in clinical trials is the use of the
run-in (Lang 1990), where potential subjects have an opportunity to
practice study procedures (e.g., return questionnaires each week, take
study medication according to schedule) and are selected for the study
on the basis of their ability to conform to those procedures. This
strategy is also seen in studies that require patients to demonstrate
their ability to become abstinent or their motivation for treatment
before program entry. In such studies, patients entering the trial are
more likely to be retained, to be compliant, and to have better
response to treatment; however, it is less likely that results will
generalize to other settings or studies that do not make such stringent
demands on patients prior to entering treatment.
8
Anticipate Heterogeneity
When patient heterogeneity is built in to a study, higher attrition is
likely. For example, the author’s cocaine studies and Project
MATCH were intended to evaluate the types of patients who respond
to different treatments, thus heterogeneous samples were recruited
and inclusion and exclusion criteria were broad by design. It was found
that within the boundaries of study treatments and the research
protocol, anticipating and accommodating the needs of diverse
patients may prevent practical and clinical problems and, ultimately,
attrition. For example, in studies hoping to recruit and retain
substantial numbers of women, the provision of child care while
patients attend treatment and research appointments may be critical.
For subjects who work, it may be impractical to ask them to come to
sessions during regular office hours, so offering some evening
appointments may help retain patients. Similarly, to retain socially
unstable or homeless patients, providing transportation to the clinic
and establishing links to social service agencies may be needed to help
subjects develop at least a minimum level of social stability to support
them while in outpatient treatments.
It should be noted, however, that some of the strategies described in
this section and the next essentially change the nature of the
treatments provided and thus their use in any given trial must be
considered carefully and monitored closely.
Build Flexibility into Treatments and Treatment Manuals
Another problem associated with a broad range of patients in a
clinical trial is that heterogeneity may increase the number of
patients who are less than ideally suited to study treatments and
therefore at risk of attrition. In studies of psychosocial treatments,
investigators may address this issue by helping therapists strike an
appropriate balance between the need to adhere to a structured
treatment manual and meeting the needs of individual patients. For
example, in psychotherapy studies conducted by the author’s group,
sessions typically begin with 15 to 20 minutes of less structured time
(conducted within a framework consistent with the theoretical
underpinnings of that treatment type), where major events since the
last session are reviewed and the patient is given the opportunity to
raise questions or concerns. For the remainder of the session,
therapists attempt to work material raised by the patient into
discussion of the manual-driven session topic for that week so as to
9
respond to the patient’s immediate concerns and maximize each
session’s relevance.
Flexibility and the ability to treat several different types of patients
within a single treatment approach also characterized the process of
developing treatment manuals for Project MATCH. In the manuals
(Kadden et al. 1992; Miller et al. 1992; Nowinski et al. 1992),
guidelines were provided, for example, for treating patients at
different settings, and with varied levels of severity and
psychopathology. In addition, therapists’ ability to be responsive to
the needs of individual patients was built into the treatment manuals
themselves. For example, both the cognitive-behavioral and 12-step
facilitation manuals included a small set of core session topics that
were considered essential to deliver for each patient to have received
an adequate dose of that treatment, but each manual also included
several elective sessions that addressed special issues or concerns (e.g.,
coping with depression, learning assertive responding). After
covering the material in the essential core sessions, the therapist and
patient could select additional elective topics in order to tailor the
treatment for each patient (Carroll et al. 1994a).
Also, to handle crises that might arise in a highly diverse sample,
therapists in each condition were allowed to offer up to two
emergency sessions. Emergency sessions were conducted within the
frame of reference and using techniques consistent with each
treatment type. For example, when problems and crises arose,
cognitive-behavioral therapists modeled a problemsolving approach,
12-step facilitation therapists encouraged their patients to deepen
their involvement in Alcoholics Anonymous (AA), and motivational
enhancement therapy (MET) therapists invited their patients to
explore and make use of resources already available to them (Carroll
et al. 1994a).
Finally, investigators may make use of safety nets to protect patients
who do not respond to study treatments. For example, most clinical
trials specify a set of clinical deterioration criteria where patients who
respond poorly to their assigned study treatment can be withdrawn
and provided a more intensive level of care. Beyond preventing
therapists from deviating from the treatment protocol with more
difficult patients (as they know they will not be asked to persist
indefinitely with a treatment that is not helpful to a patient), these
procedures, if made explicit to patients, may prevent some patients
from dropping out without giving treatment a reasonable try by
reassuring them they will receive more intensive treatment if
clinically indicated.
10
Involve Significant Others
Involvement of significant others in treatment has long been
recommended as a technique to improve retention in general
(Meichenbaum and Turk 1987) and has been shown to be beneficial in
treatment of substance dependence (e.g., DeLeon 1991; Higgins et al.
1994; Sorenson et al. 1985). Thus, in the author’s clinical trials,
therapists are allowed to offer up to two significant-other sessions
(which are closely monitored and analyzed as process variables).
Guidelines for conducting these sessions are described in the respective
treatment manuals, and are designed not as family therapy but rather
an opportunity for family members to learn what the patient’s
treatment and involvement in the research encompasses, ask
questions and express concerns, and participate in future treatment
planning. Thus, by accommodating significant others and attempting
to make them allies of the research team, the therapists seek to
prevent sabotaging of treatment, which might be more likely to occur
if significant others were excluded entirely.
STRATEGIES RELATED TO THERAPISTS
While investigators cannot necessarily select patients who will be
retained, it may be possible to select study therapists who are more
likely to hold on to patients. Some strategies are described below.
Careful Selection of Therapists
Investigators should strive to select therapists who are likely to be
good fits for the treatment protocols and who can work well with a
variety of patients. While specific therapist selection criteria vary
across studies, therapist selection criteria typically include:
completion of a terminal degree in the therapist’s discipline (usually
an M.D., Ph.D., or M.S.W.); several years of clinical experience with
a population closely related to the study population; and experience
in and commitment to the type of study treatment the therapist will
be conducting in the trial (Carroll et al. 1994b; Chevron et al. 1983).
Use of comparatively stringent criteria to promote a highly
experienced therapist cohort is important. Therapists’ training in
clinical trials is typically (and necessarily) limited to helping them
adjust their usual approach to fit manual guidelines; there is no
opportunity to teach basic therapy skills to novice clinicians
(Rounsaville et al. 1986).
11
In addition to meeting selection criteria, the author and colleagues
typically require therapist candidates to submit a videotaped work
sample. By viewing a therapist’s actual work, researchers can
appraise a number of key qualities that would be impossible to
evaluate on the basis of a curriculum vitae alone. For example,
Luborsky and colleagues (1985, this volume) identified several
characteristics associated with retention and outcome of substanceabusing patients including the therapist’s interest in helping, skill, and
ability to form a good working relationship (alliance). Finally,
requesting a videotaped work sample is a good introduction for the
therapists to the increased scrutiny required in clinical trials of
psychosocial treatments (e.g., videotaping of all sessions, frequent
supervision, and process evaluation). Experience suggests that
therapist candidates who refuse to submit work samples generally have
good reason for doing so.
Moreover, with the growth of interest in patient-treatment matching
studies and the resultant need to deliver highly distinct treatments
with a minimum of overlap (Carroll et al. 1994a), it is important to
ascertain that therapist candidates are competent practitioners of the
treatment type to which they profess commitment. It is extremely
difficult, for example, both to train and prevent overlap in behavioral
therapists who profess to do dynamic therapy and in 12-step-oriented
therapists who say their approach is cognitive-behavioral.
It is also important to recruit therapists who are open to working with
substance abusers. Investigators should note that not all therapists are
good at this work. Some very competent therapists who are
experienced in working with other types of patients have strong
opinions about the value (or lack thereof) in conducting
psychotherapy with substance abusers. If such attitudes are not
identified and addressed, therapists who have low expectations of
patient success may convey these expectations in a number of ways
(e.g., conveying a lack of optimism about the patient’s chance for
success, prematurely diagnosing their patients as having antisocial
personality disorder) and undermine retention (Baekeland and
Lundwall 1975).
Address Retention as Part of Therapist Training
Therapist training provides another important opportunity for
heightening the importance of retention in the trial and selecting out
therapists who are less likely to hold patients. For example, during
initial didactic training seminars where the therapists are introduced to
12
the goals and aims of the trial and the treatment manuals are
reviewed, it is helpful to underline the importance of retention and
the expectation that the therapists will make special efforts to retain
their patients. It may be helpful to highlight and discuss differences
between being a therapist in research clinical trials versus regular
clinical practice (Weissman et al. 1982), including random
assignment, the short-term nature of treatment, and the high level of
scrutiny around treatment delivery. Substantial attention also is
devoted during training to working through issues of patient
heterogeneity, that is, helping therapists develop strategies for
successfully retaining patients who vary with respect to severity,
psychopathology, motivation, and other characteristics within their
treatment approach. Thus prepared, therapists may feel less tempted
to borrow from other approaches or give up on patients when they
confront difficult clinical issues during the study.
Training therapists for clinical trials designed to evaluate
psychotherapeutic treatments also requires completion of several
closely supervised practice cases; this is intended to help therapists
gain experience adapting their usual approach to be consonant with
the treatment manuals and research procedures. Supervision is also an
opportunity to reinforce the importance of retention by attending to
and addressing any missed sessions or dropouts. Again, while even
experienced therapists can have some difficulty with training cases, it
has been found that therapists whose patients frequently drop out
during training are often those with poorer retention during the main
phase of the trial.
Build in Therapist Incentives for Retention
In regular treatment clinics where therapists’ caseloads are heavy,
missed sessions are often experienced by the therapists as good
fortune, giving them precious extra hours to catch up on paperwork
and phone calls. Thus, there is little incentive to follow up on
patients who miss sessions and attempt to shore up connections with
treatment where resolve may be tenuous. By not following up on
such patients, therapists can passively cull their caseload of patients
they perceive as unmotivated, disagreeable, time consuming, or
otherwise unappealing.
Conversely, in clinical trials, a great deal of time and many valuable
resources are devoted to recruitment, screening, preparation, and
assessment of each subject. Loss of a single subject is costly
practically as well as statistically. To heighten therapists’ awareness
13
of the importance of retention, it may be useful to build in incentives
for retention. For example, rather than paying all or part of study
therapists’ salaries, therapists are paid on a per diem basis, where they
receive an hourly fee for every hour of patient contact. Thus, as
their earnings will be reduced if their patients leave treatment, there is
incentive to attend to early problems in developing a relationship,
and to call and follow through with patients who are late or no-shows.
Close Monitoring of Therapists
Close attention to the therapists’ delivery of study treatments and
level of competence may also improve retention. Video- or
audiotaping all sessions, which is done primarily to facilitate process
analyses and evaluation of treatment discriminability, may also
increase the quality of treatment and possibly reduce attrition. For
example, therapists who are aware that everything they say to a
patient is being taped and evaluated may be more likely to be
consistently diligent about delivering study treatments and perhaps to
deliver better, higher quality treatments. Provided consistently and
carefully, ongoing supervision itself may increase the quality of
treatment and increase retention by providing support, bolstering
morale, and broadening therapists’ repertoire by working through
issues raised by difficult patients. Supervisors should be particularly
alert to attrition and explore with each therapist the process that may
have led to patients leaving treatment and missing sessions. Ongoing
attention to warning signs of attrition, especially missed
appointments, also may be helpful.
Stability and Flexibility
Patients whose sessions are scheduled to occur at the same time each
week tend to be more likely to complete treatment. While some
variability in the structure of scheduling may be patient determined
(e.g., patients who are using, with unstable work schedules or family
life, are unlikely to come in the same time each week), it is important
that therapists understand the need for consistency and the
undesirability of varying the schedule of sessions and missing sessions.
Moreover, stability and flexibility can be improved through having a
larger pool of trained study therapists. Besides reducing the likelihood
of therapist effects (Crits-Christoph and Mintz 1991), having more
therapists ready to deliver study treatments may prevent the need to
interrupt treatment for therapist vacations and other absences.
Furthermore, a larger therapist pool may increase flexibility in
14
accommodating the needs of individual patients such as patients with
unusual schedules, patients who express a strong preference for a male
or female therapist, and other considerations.
STRATEGIES RELATED TO INVESTIGATORS AND RESEARCH
STAFF
Research staff can use many strategies to improve retention in
clinical trials. Several have been recognized for many years and few
are limited to the special needs of substance abusers. For example, the
general principles recommended by Meichenbaum and Turk (1987)
are applicable, including short referral times, involving the patient in
the planning and implementation of the treatment program, using
reminders, discussion of the reasons for previously missed
appointments, patient education, fostering a collaborative
relationship based on negotiation, involvement of significant others,
being patient oriented, and reducing the level of complexity of the
protocol.
As with the other strategies listed above, it is important to note that
only some of the following have been evaluated empirically for their
actual impact on retention. More studies specifically evaluating these
strategies and others are clearly needed. Furthermore, as these
strategies may have an effect on retention and outcome, it is
important for investigators using these strategies to monitor that
they are applied appropriately and consistently across study
conditions.
Rapid Response and Assignment to Treatment
Patients may never be more motivated than the first time they call
the clinic. Several studies have shown that by cutting down the time
between application for treatment and first contact, retention can be
improved significantly (Baekeland and Lundwall 1975; Leigh et al.
1984; Stark et al. 1990). Furthermore, research screening and
assessment procedures, including medical evaluations and lengthy
diagnostic interviews, can delay randomization and the start of
treatment to up to 1 month. Rates of successfully starting patients in
the protocols have increased as the author’s group reduced the
interval between first contact to first treatment session to less than 1
week. Alternatively, lengthening the pretreatment patient evaluation
period is akin to a run-in period, which may reduce the number of
15
patients who enter the protocol, but may in turn produce a more
compliant sample of patients more likely to be retained.
Subject Preparation and Inoculation
Building on the broader literature on the effectiveness of roleinduction procedures for general psychotherapy patients as a strategy
to improve retention (Hoehn-Saric et al. 1964), some investigators
have found these procedures (including educating subjects regarding
their role as drug abuse treatment patients or research subjects) helpful
among substance abusers. For example, Stark and Kane (1985) found
that a drug treatment-specific role induction procedure was more
effective in increasing rates of return for second appointments than
was a standard intake interview. Sutherland and colleagues (1985)
reported that new subjects meeting with a research psychologist (who
conducted a research interview that included extensive self-reports of
substance abuse and a request to fill out a drinking diary) had
significantly better rates of attendance at subsequent sessions than
those who saw only a drug counselor (71 percent versus 43 percent).
Brown and Miller (1993) found that two sessions of motivational
interviewing significantly improved treatment involvement and
outcome compared to no such preparation.
Thus, in the author’s clinical trials, study staff spend on average at
least 2 hours with each patient explaining the study, its procedures,
the implications of random assignment, the roles of the treatment
and research staff, the benefits and risks of study participation, the
nature of the treatment that may be received, the likely duration of
assessment sessions, the importance of collecting accurate data, and
why videotaping of treatment sessions is done. Study staff also
prepare handouts containing this information; the handouts are
intended to clarify the treatment protocol, inoculate patients against
disappointment or surprise, and help them prepare for their roles as
patients and research subjects. Potential barriers to study
participation such as transportation and child care problems, work
schedules, vacations, meetings with probation officers, and court
cases, are ferreted out and discussed in advance. For example, the
study staff routinely review a calendar with the patient, pointing out
days when the patient can expect to come to treatment sessions,
assessment interviews, and followups, so patients can identify
interruptions and problems and these can be worked through in
advance or avoided.
16
Frequent Contact and Monitoring
Nirenberg and colleagues (1980) found that telephone or letter
contact immediately after missed sessions significantly improved rates
of return to treatment. The author’s research colleagues assume the
patient is in the study until the patient says this isn’t so. Therefore,
if a patient misses a treatment or assessment session, research staff
call or write several times until the patient comes in or formally
withdraws. Patients are not accustomed to this level of interest, and
the clear message of concern about what happens to them can be very
persuasive if a patient is ambivalent about continuing. Patients who
choose to withdraw are asked about their reasons for doing so and
staff try to address these if possible. Also, because most study
therapists do not work at the research clinic and may be difficult to
contact on short notice, a member of the research team is available
by phone to answer questions, handle crises, or link the patient with
the therapist if necessary.
User-Friendly Practices
Attending to the details of a clinical trial, which takes consistent
effort and attention, conveys respect for the patient and may also
improve retention (DelBoca and Mattson 1994). For example, if the
assessment battery takes several hours to complete, the staff offers
the patient frequent breaks and refreshments. Assessment forms are
evaluated for grade level and ease of reading. Clean, legible copies of
assessment instruments are used. Subjects are encouraged to complete
self-report instruments at the clinic where a staff person is available if
they have questions or problems. All staff, including the security
guards and receptionists, are polite to the patients. Staff and
therapists ask the patients whether they prefer to be called by their
first or last name. Parking is close to the clinic and safe.
Personalized letters are sent to remind patients about followup
interviews. Summarizations of the major findings of the study are
sent to the patients as a means of thanking them for their
participation and maintaining contact.
STATISTICAL COPING STRATEGIES
Finally, despite investigators’ best efforts, some attrition may be
inevitable in any clinical trial (Lavori 1990). The statistical problems
associated with missing data and the flaws of many frequently used
approaches for coping with them are well known. For example,
17
traditional statistical models for analyzing clinical trial data, such as
analysis of variance (ANOVA), are very vulnerable to missing data in
that they typically result in either deletion of cases with any missing
data or imputation of missing values. Furthermore, the practice of
carrying forward endpoint ratings for patients who drop out of
treatment has been severely criticized and is particularly vulnerable to
bias when differential attrition occurs across groups (Lavori 1992).
Recently, however, sophisticated statistical models for evaluating
treatment effects have become available that are less vulnerable to
some problems associated with missing data. Random effects
regression models permit a more flexible approach for studying
change over time (Bryk and Raudenbush 1987; Hedeker, unpublished
observations) by treating time as a random as well as a fixed effect,
modeling an individual’s behavior as a function of an individual
growth trajectory and analyzing the individual change trajectories by
treatment group. Furthermore, in contrast to repeated-measures
ANOVA analyses which usually involve deleting subjects with missing
data or imputing values for missing data points, random effects
regression models allow use of all available data.
The potential value of these approaches has been demonstrated
recently by applying random effects regression models to recent
clinical trials. For example, the author and associates were able to
follow 80 percent of patients randomized to the cocaine
psychotherapy-pharmacotherapy study up to 1 year after they
completed treatment, but could not successfully reach all patients for
all followups. Analysis of the data using several different statistical
models (cross-sectional, repeated measures MANOVA, and random
regression) consistently pointed to continuing improvement, or
sleeper effects, in the groups that received relapse prevention
compared to supportive clinical management (Carroll et al. 1994b).
However, it was also found that the more restrictive MANOVA
models also indicated several spurious interaction effects related to
imputation of missing values or analyses based on non-representative
subgroups (Nich and Carroll, submitted).
SUMMARY
Given the close links between retention and outcome in substance
abuse treatment, it is important to recognize that treatments are
successful to the degree they retain patients. This chapter described
18
some practical strategies for improving retention in clinical trials of
treatment for substance abuse. To summarize:
1. Retention can be conceived as an important treatment outcome
that reflects good fit between patient, therapist, treatment, and
setting. Procedures and practices that improve the quality of
treatment are likely to also improve retention.
2. Attending to the problem of retention may help solve the
problem. While trials are ongoing, investigators should monitor
retention closely, attending to and addressing variations in
retention that might be associated with setting, seasonal
variations, therapist factors, and research procedure factors.
3. More data are needed on effective methods of enhancing
retention in different treatment settings. It should be noted that
the strategies presented here reflect common sense and are for the
most part drawn from experience with several clinical trials. Few
of them have been evaluated empirically. However, more data on
effective retention strategies are likely to have broad clinical and
research utility. For example, it would be possible to design
studies that evaluate an adaptation of Higgins’ voucher system
(this volume) to specifically reinforce retention in treatments
that have higher rates of attrition, different methods of rewarding
clinicians with higher rates of retention, and the effect on
retention of adding babysitting services, to mention but some
areas where further research would be illuminating.
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ACKNOWLEDGMENTS
Support was provided by NIDA grants RO1-DA04299 and
R18-DA06963 and NIAAA Cooperative Agreement U10 AA08430.
AUTHOR
Kathleen M. Carroll, Ph.D.
Department of Psychiatry
Yale University School of Medicine
Substance Abuse Center/S208
34 Park Street
New Haven, CT 06519
24
From the Initial Clinic Contact to
Aftercare: A Brief Review of
Effective Strategies for Retaining
Cocaine Abusers in Treatment
Stephen T. Higgins and Alan J. Budney
Psychosocial and pharmacological treatments for cocaine abuse are
associated with high rates of attrition (e.g., Gawin et al. 1989; Higgins
et al. 1993; Kang et al. 1991; Weddington et al. 1991). This is
particularly unfortunate because poor drug abuse treatment retention
is associated with poor outcomes. For example, several studies report
that longer treatment duration predicts improved outcome: the Drug
Abuse Reporting Program (DARP) (Simpson 1984), the Treatment
Outcome Prospective Study (TOPS) (Hubbard et al. 1984), programbased evaluation research in therapeutic communities (DeLeon 1984),
and research on the efficacy of methadone maintenance treatment
(Ball and Ross 1991). Definitions of outcome varied across these
studies, but typically included drug abstinence. Across all of these data
sets, treatment durations of 3 months or more predicted improved
outcome, and in some reports the degree of improvement was
proportional to the length of time spent in treatment (Simpson
1984).
Results from more recent studies that focused exclusively on cocaine
abuse also support a positive relationship between treatment retention
and outcome. Wells and colleagues (1994), for example, examined
abstinence in a group of 92 cocaine abusers who participated in an
outpatient trial in which they received relapse prevention therapy or
a 12-step support group. Across the two treatment groups, greater
retention, defined as more treatment sessions, predicted less cocaine
use at posttreatment and 6-month followup. Similarly, Carroll and
coworkers (1993) followed 150 cocaine abusers who applied for
inpatient or outpatient treatment and assessed the relationship
between total days enrolled in treatment from any source during the
year after baseline interview and 12-month abstinence. Abstinent
subjects had significantly more days in treatment than did
nonabstinent subjects.
Thus, treatment retention is associated with positive outcomes in drug
abuse treatment in general and cocaine abuse treatment in particular.
Of course, no causal inferences can be based on these correlations.
25
The greater amount of treatment received by individuals who are
retained longer may indeed cause the greater reductions in drug use and
other positive behavior changes observed in them, but equally
plausible are the possibilities that those very improvements in
reducing drug use and related behaviors cause individuals to remain in
treatment longer, or that some third variable(s) causes both the
greater treatment retention and improved outcomes. Controlled trials
experimentally manipulating the duration of treatment are needed to
determine which of these three (or more) possibilities is more
accurate.
Despite these limitations in the understanding of the relationship
between treatment retention and other outcome measures,
considerable interest exists in identifying methods to improve
retention of cocaine and other types of drug abusers in treatment.
This chapter reviews the published literature on effective
interventions for improving retention in cocaine abusers. While still
few in number, effective strategies have been identified for addressing
the following three basic issues regarding retention in treatment for
cocaine abuse: (1) increasing retention between initial clinic contact
and intake appointment, (2) increasing retention during treatment,
and (3) increasing retention between discharge from treatment and
entry into aftercare. This review includes only controlled clinical
trials conducted with cocaine abusers. Studies conducted with cocaine
abusers enrolled in methadone maintenance therapy were excluded
because the relatively high retention rates associated with that
therapy would likely increase the probability of type II errors
regarding effects of other interventions on retention.
ATTENDING INITIAL INTAKE APPOINTMENTS
The authors are aware of one experimental study that has reported
identifying an effective strategy for increasing attendance at initial
intake appointments in cocaine abusers (Festinger et al., in press).
Seventy-eight cocaine abusers who contacted an urban, outpatient
treatment clinic were randomly assigned to either an accelerated or
standard intake condition. In the accelerated condition, interviews
were scheduled on the same day as the initial contact or on the
morning of the next business day if the contact had been made after 3
p.m. In the standard condition, interviews were scheduled 1 to 3 days
after the initial contact. Fifty-nine percent (23/39) of those assigned
to the accelerated protocol attended their scheduled interview versus
33 percent (13/39) of those assigned to the standard protocol (p <
26
0.05). No significant differences in retention rates during treatment
were discerned between patients entered via the accelerated and
standard procedures, with the former and latter groups attending a
mean of 11.1 and 10.1 therapy sessions, respectively.
RETAINING COCAINE ABUSERS DURING TREATMENT
Psychosocial Interventions
Six controlled trials have been reported in which a psychosocial
intervention increased retention during treatment for cocaine abuse
(table 1). Two of those studies compared a multicomponent
behavioral treatment to drug abuse counseling from a disease-model
orientation (Higgins et al. 1991, 1993). The first of those two trials
was 12 weeks in duration and assigned consecutively admitted patients
to the two treatment groups, while the second study was 24 weeks in
duration and randomly assigned patients to the two treatments.
These treatments have been described in detail previously and are
only briefly outlined in this report (see Higgins et al. 1993, 1994a).
The behavioral treatment combined a contingency-management
program with the community reinforcement approach (CRA). In the
contingency-management program, patients earned incentives in the
form of vouchers redeemable for retail items contingent on
submitting objective evidence of recent cocaine abstinence (i.e.,
cocaine-negative urinalysis). The value of the vouchers increased
with each consecutive negative urinalysis test and cocaine-positive
tests reset the value of the vouchers back to their initial low value.
CRA therapy systematically promoted improvements in patients'
family relations, social and recreational practices, vocation, and
reductions in other drug use. Drug abuse counseling consisted of
supportive and confrontational individual and group therapy, didactic
lectures and videotapes on cocaine dependence, reliance on the disease
model of addiction, and a self-help orientation. Across both trials,
retention was significantly better in the behavioral than the drug abuse
counseling groups. In the first study, 85 percent (11/13) of subjects
assigned to the behavioral group completed 12 weeks of treatment
versus 42 percent (5/12) of those assigned to drug abuse counseling (p
= 0.03). In the second study, 58 percent (11/19) of subjects assigned
to the behavioral treatment completed 24 weeks of treatment
compared to 11 percent (2/19) of patients assigned to drug abuse
counseling (p < 0.01).
27
Treatment
comparisons
No. of
subjects
Inpatient
vs.
day hospital
55
Relapse prevention
vs.
interpersonal psychotherapy
21
Behavioral
vs.
drug abuse counseling
13
Behavioral
vs.
drug abuse counseling
19
Behavioral plus incentives
vs.
behavioral
20
Study
Psychosocial interventions
Alterman et al. 1994
Carroll et al. 1991
Higgins et al. 1991
Higgins et al. 1993
Higgins et al. 1994b
Treatment
duration
28-31 days
89%
vs.
54%
12 weeks
86%
vs.
57%
12 weeks
85%
vs.
42%
completed treatment
24 weeks
58%
vs.
11%
completed treatment
24 weeks
75%
vs.
40%
completed treatment
56
21
15
19
20
28
Significant retention effect
completed treatment
completed Æ 4 weeks
of treatment
Treatment
comparisons
No. of
subjects
Residential w/children
vs.
residential
31
Study
Hughes et al. 1994
Pharmacological interventions
Batki et al. 1994
Gawin et al. 1989
Fluoxetine
vs.
placebo
Treatment
duration
18 months
300
vs.
102
12 weeks
11
vs.
3
6 weeks
37.9
vs.
32.7
vs.
30.6
22
32 total
Desipramine
vs.
lithium
vs.
placebo
24
24
24
29
Significant retention effect
mean days of treatment
median weeks of
treatment
mean days of treatment
The third study relevant to this section was designed to
experimentally dismantle this multicomponent behavioral treatment
to identify its active components (Higgins et al. 1994b). Forty
patients were randomly assigned to the behavioral treatment with (N
= 20) or without (N = 20) the incentive program in which patients
earned vouchers by submitting cocaine-free urine specimens. The
trial was 24 weeks in duration. The voucher program was in effect
during weeks 1 to 12 of the trial, while during weeks 13 to 24 the two
groups were treated the same. Seventy-five percent of patients
assigned to the voucher group were retained for 24 weeks of
treatment versus 40 percent in the no-voucher group (p = 0.03).
The fourth positive study randomly assigned 42 cocaine abusers to
either relapse prevention or interpersonal psychotherapy treatment
groups (Carroll et al. 1991). Relapse prevention is a cognitivebehavioral treatment that includes techniques to identify
environmental and personal risk factors for drug use and provide skills
training to help clients avoid high-risk situations and effectively cope
with urges to use drugs. Interpersonal psychotherapy promotes
changes in patients' interpersonal relations in order to resolve their
drug use. The study was 12 weeks in duration and involved onceweekly individual therapy delivered by advanced graduate students in
clinical psychology. Retention generally was higher in the relapse
prevention group than the interpersonal psychotherapy group
throughout the 12 weeks of treatment, but those differences were
statistically significant only at week 4 (89 percent versus 57 percent,
p < 0.05). Total number of dropouts was nearly twice as high in
interpersonal psychotherapy than relapse prevention (13 versus 7),
but that difference was not statistically significant.
Two subsequent trials examining the efficacy of relapse prevention
have been reported. One compared it to case management in a
randomized design with cocaine-dependent patients (Carroll et al.
1994) and the other compared it to 12-step-based counseling in an
alternate-assignment trial with cocaine abusers (Wells et al. 1994).
Each failed to observe significant differences between treatment
groups in retention, but rates were somewhat higher in relapse
prevention than in the comparison treatments in both trials.
In the fifth positive trial, cocaine-dependent adults (N = 111) were
randomly assigned to a day hospital or inpatient treatment program
(Alterman et al. 1994). Both programs were 28 days to 1 month in
duration, utilized group therapy, and focused on overcoming patient
denial, teaching everyday coping skills, and providing instruction on
30
environmental cues associated with relapse. Eighty-nine percent of
patients assigned to inpatient treatment completed treatment versus
54 percent assigned to the day hospital program (p < 0.001).
In the sixth and final positive trial in this section, 53 cocaine-abusing
women were randomly assigned to an 18-month residential treatment
in which they could (N = 31) or could not (N = 22) bring one or two
of their children to live with them (Hughes et al. 1995). Those
assigned to the group that could bring children had a significantly
longer mean length of stay (300 days) than those assigned to the
group that excluded children (102 days) (p < 0.05).
Pharmacological Interventions
Two placebo-controlled, randomized trials were identified in which a
pharmacotherapy for cocaine abuse significantly improved treatment
retention (see table 1). The first was a 6-week trial comparing
desipramine hydrochloride (2.5 milligrams per kilogram (mg/kg) body
weight), lithium carbonate (600 mg), and placebo in 72 cocainedependent outpatients (Gawin et al. 1989). All subjects also received
once-weekly individual, interpersonal psychotherapy. Subjects
assigned to desipramine remained in treatment for an average of
37.9+1.6 days versus 30.6+2.5 and 32.7+2.3 days in the placebo and
lithium groups (contrast of desipramine versus others: p = 0.02).
The second positive report was a 12-week trial comparing fluoxetine
(40 mg/day) and placebo in 32 cocaine-dependent outpatients (Batki
et al. 1994). Subjects in the fluoxetine group were retained for a
median of 11 weeks versus 3 weeks for the placebo group (p < 0.01).
Each of these positive trials is countered by negative trials in which
desipramine or fluoxetine failed to improve retention. Five
randomized, controlled trials have been reported in which desipramine
failed to improve retention (Carroll et al. 1994; Giannini et al. 1987;
McElroy et al. 1989; Tennant and Tarver 1985; Weddington et al.
1991); similarly, the positive results with fluoxetine reported by Batki
and colleagues (1994) must be weighed against the negative results
from a placebo-controlled trial reported by Grabowski and colleagues
(1995). In that trial, 228 cocaine-dependent patients were
randomized to one of three drug conditions (placebo, 20, and 40
mg/day fluoxetine) and one of two different frequencies of weekly
clinic visits to pick up medication (2 or 5 days per week). All
patients participated in individual cognitive behavior therapy sessions
once per week. The study included a 2-week stabilization period
followed by a 12-week trial. Of the 228 patients the stabilization
31
period and entered the 12-week trial. Dropout rates during
stabilization did not differ between the treatment groups, but
retention during the trial was significantly lower in those assigned to
active medication versus placebo (p = 0.04). Moreover, retention
varied as a graded function of dose (p < 0.05). The placebo group had
the best retention rate, followed by the 20 mg group, with the lowest
retention rate being observed in the 40 mg group (placebo > 20 mg >
40 mg). Visit frequency also significantly affected retention (p =
0.0001), with patients assigned to the low-frequency schedule of clinic
visits being retained longer than those assigned to the high-frequency
schedule.
It merits mention that preliminary results from an ongoing,
randomized trial suggest that desipramine and flupenthixol decanoate
may increase treatment retention in cocaine abusers compared to
placebo when the medications are administered in an outpatient
setting in which minimal psychotherapy is provided (Khalsa et al.
1994).
INCREASING AFTERCARE PARTICIPATION
Positive effects on aftercare entry have been reported in three
controlled trials; all were psychosocial interventions. For two
(Higgins et al. 1993, 1994b), aftercare results were included in a
followup report published after initial outcomes were reported (see
Higgins et al. 1995). In one of the two trials mentioned above
comparing the multicomponent behavioral treatment and drug abuse
counseling (Higgins et al. 1993), 4 of 19 (21 percent) subjects in the
behavioral treatment entered aftercare versus zero of 19 in the drug
abuse counseling group (p = 0.03). Similarly, in the trial described
above comparing the behavioral treatment with versus without the
voucher program (Higgins et al. 1994b), 14 of 20 (70 percent)
subjects in the group with vouchers versus 6 of 20 (30 percent) in the
group without them enrolled in aftercare (p = 0.01). In both trials,
the differential rates of aftercare entry appeared to follow directly
from the differences in retention rates observed across the
treatments; that is, those treatments that engendered higher retention
rates were also more likely to have patients enter aftercare.
That logic does not hold for the third trial relevant to this section,
which is the day hospital program versus inpatient treatment
comparison described above (Alterman et al. 1994). Despite
significantly higher retention rates in the inpatient treatment group
32
in that study, no significant treatment differences were discerned in
the number of patients who entered aftercare. Twenty-five (45
percent) patients assigned to day hospital versus 17 (31 percent)
patients assigned to inpatient treatment entered aftercare (N.S.).
Interestingly, significant treatment differences in the number of
treatment completers who entered aftercare emerged favoring the day
hospital group. Twenty-five of the 30 patients (83 percent) who
completed day hospital treatment entered aftercare versus 17 of the
49 patients who completed inpatient treatment (p < 0.01). Thus,
while less effective in retaining patients in treatment, the day hospital
treatment was more effective than inpatient treatment in fostering
aftercare participation in treatment completers.
No published reports noting positive outcomes of pharmacotherapies
on aftercare entry were identified, although preliminary results from
an ongoing trial suggested that desipramine may facilitate transition
from inpatient care to outpatient aftercare when the blood levels of
the medication are in the therapeutic range (Hall et al. 1994).
RELATIONSHIP OF RETENTION TO COCAINE ABSTINENCE
An obvious and important issue is whether the improved retention
rates observed in these trials were associated with greater cocaine
abstinence. Abstinence data were not reported in the trial examining
accelerated intakes and thus there is no way to know how that
practice relates to cocaine abstinence (Festinger et al., in press).
Abstinence data were included in seven of the eight reports shown in
table 1 regarding retention in treatment (the exception being Hughes
et al. 1995). Significantly greater cocaine abstinence was documented
in the treatment groups with superior retention in five of those seven
reports (Batki et al. 1994; Gawin et al. 1989; Higgins et al. 1991,
1993, 1994b); a nonsignificant trend in the same direction was
evident in a sixth report (Carroll et al. 1991). The exception was the
Alterman and colleagues' study (1994) in which inpatient treatment
was more effective in retaining patients during the initial treatment
period while day hospital treatment was more effective in getting
completers to enter aftercare. No significant treatment group
differences were discerned in abstinence levels assessed at 7-month
followup. In the two other trials in which there were treatment group
differences in the number of patients who entered aftercare,
significantly more abstinence was observed in the treatment groups
with greater aftercare participation (Higgins et al. 1995). Thus, in
33
the majority of studies, treatments that increased retention also
increased cocaine abstinence.
CONCLUSIONS
The most important conclusion to be drawn from this brief review is
that the high rates of attrition so commonly observed with cocaine
abusers are not inevitable. Strategies can be devised to improve
retention between the initial clinic contact and intake interview,
during the treatment episode, and between completion of treatment
and entry into aftercare.
The efficacy of accelerated intakes is encouraging in that it illustrates
how a relatively minor change in clinic policy can substantially alter
attrition rates (Festinger et al., in press). Reported attendance rates
at the initial intake interview in the work by Festinger and colleagues
(in press) increased 1.8-fold in the accelerated procedure. The
comparable retention rates observed during treatment in that study
suggest that accelerated procedures do not necessarily result in the
admission of a larger proportion of individuals who are unmotivated
for treatment relative to standard admission procedures.
Results from one controlled and two uncontrolled studies also support
the efficacy of accelerated intake procedures. In a controlled trial
conducted with a mixed sample of different types of drug abusers (35
percent primary cocaine abusers), consecutive callers to an urban
outpatient drug abuse clinic were randomly assigned to either a
condition wherein they had the option to come to the clinic
immediately or were provided an intake appointment that on average
was scheduled 9.7 days after the initial contact (Stark et al. 1990).
Having the option to come immediately significantly increased
attendance relative to the scheduled appointment. However, duringtreatment dropout rates were higher in those provided the immediate
option than the standard appointment, suggesting that there are
instances where accelerated intake procedures can increase subsequent
attrition rates.
Before undertaking the experimental study described above, Festinger
and colleagues (Festinger et al. 1995) retrospectively examined data
from 232 initial clinic contacts for cocaine abuse treatment. The best
predictor of whether a client would attend the intake session was
whether the appointment was scheduled on the same day as the initial
contact. Retention data were not reported in that study. Finally,
34
effects of same-day versus delayed intakes were examined in a
methadone maintenance clinic using an A-B design (Woody et al.
1975). Results were reported as retention rates during months 2 to 5
after admission. Moving from a practice of completing intakes on 2
designated days per week to conducting them on the same day as the
initial contact significantly increased the proportion of patients
retained during the 4-month observation period. The accelerated and
standard groups both evidenced a steady dropout rate across the
observation period. However, there were no differences between the
groups on that measure, which is consistent with the findings of
Festinger and colleagues (in press) that those entered via accelerated
procedures are no less likely to remain in treatment than those
admitted via standard procedures. In summary, then, the efficacy of
accelerated procedures for increasing attendance at the intake
interview is consistent across four studies in cocaine and other types
of drug abusers, and during-treatment dropout rates were comparable
across the accelerated and standard admission procedures in two of the
three studies in which that information was reported.
Briefly, there is another study using a mixed sample of drug abusers
(31 percent primary cocaine abusers) that merits mention (Stark and
Kane 1985). As with the accelerated intake work, it also illustrates an
effective strategy for combating the high rates of attrition associated
with the intake process using an intervention involving minimal
clinical effort. Applicants for outpatient treatment were randomly
assigned to one of four conditions immediately following their intake
interview: (1) 15-minute general orientation regarding what to
expect from psychotherapy, (2) 15-minute specific orientation
regarding what to expect from psychotherapy for drug abuse, (3) 15minute general drug education, or (4) a no-treatment control. The
specific orientation to psychotherapy for drug abuse significantly
increased the proportion of patients who returned for a second visit
by 19 to 40 percent compared to the other treatment groups.
Considerable dropout was observed in all groups during the subsequent
90 days. However, all groups were comparable on that measure,
suggesting that the advantage of the specific orientation procedure
was not nullified by a subsequent higher dropout rate. Because results
from cocaine abusers were not described separately in this report, the
efficacy of this procedure in that population remains unclear.
However, considering the minimal effort involved and the large
effects observed, it certainly merits further investigation in cocaine
abusers.
35
Accelerated intakes, and perhaps a brief orientation session, can
improve the proportion of patients who complete the intake process
and enter treatment, but the challenge of how to effectively retain
them during treatment is not addressed by those procedures. The
studies by Higgins and colleagues do address that challenge, and
demonstrate that providing a structured, behavioral intervention that
includes incentives can improve treatment completion rates by as
much as fivefold compared to drug abuse counseling, and almost
twofold compared to the same behavioral treatment without
incentives (Higgins et al. 1991, 1993, 1994b). At this time, the
efficacy of that approach for retaining cocaine abusers during
treatment has more empirical support than any other strategy. Each
of the three trials demonstrating the efficacy of this treatment for
increasing retention was conducted in the same clinic, which is located
in a small metropolitan area with an almost exclusively caucasian
population. Thus, replications in other settings are needed, especially
clinics located in large urban areas with minority populations.
However, the generality of the incentive program used in that
treatment to urban clinics and to minority patients has been
demonstrated in two trials examining effects on cocaine abstinence
(Silverman et al. 1995; Tusel et al. 1995). Both trials were conducted
in methadone maintenance clinics, which precluded assessing effects
on treatment retention. However, considering that the incentives
improved cocaine abstinence in both trials, there is evidence that they
are efficacious in those settings and thus may increase retention as
well.
An obvious concern regarding the use of incentives in any setting is
cost. The incentives used in the studies by Higgins and colleagues
increased treatment costs by approximately $600 per patient. While
such extra costs pale when considered against the costs of inpatient
hospitalizations for substance abuse (Alterman et al. 1994; Holder and
Blose 1991), or the costs associated with treating the adverse
consequences of drug abuse (e.g., acquired immunodeficiency
syndrome (AIDS), prenatal drug exposure) (Drucker 1986; Phibbs et
al. 1991), many community clinics are likely to be unable or unwilling
to incur such extra costs. Hence, strategies for making incentives
available for use in community clinics that require no additional
financial expenditure on the part of the clinic are needed. Using
access to public resources such as athletic or cultural facilities or
requesting local businesses to donate retail items for use as incentives
have been suggested previously (Higgins et al. 1994a). There may be
any number of potential strategies of this type for implementing
incentive programs in community clinics that would be efficacious and
36
fiscally feasible, although devising and managing them obviously will
require considerable creativity and effort. When the potential
therapeutic benefits of incentives are considered, such strategies
certainly appear to merit exploration.
The initial trial by Carroll and colleagues (1991) suggested that
relapse prevention may be an effective intervention for improving
retention during outpatient treatment for cocaine abuse. However,
that was less clear in the two subsequent trials in which relapse
prevention was associated with somewhat higher retention rates than
comparison treatments, but those differences were not statistically
significant (Carroll et al. 1994; Wells et al. 1994). Nevertheless,
considering the significant challenge that retaining cocaine abusers
during treatment represents, and the positive trends evident across
trials, relapse prevention certainly warrants further evaluation.
The finding that retention of cocaine-abusing mothers during
residential treatment is improved by allowing their children to reside
with them lends empirical support to a strategy that makes a great
deal of practical sense (Hughes et al. 1995). Of course, this was only
a single study. Thus, further information will be necessary to evaluate
the value of this particular strategy. However, this study focuses
attention on the more general issue of practical barriers to treatment
completion. That is, drug abusers are faced with the same basic
demands on their time that all of us confront. Efforts to identify how
those everyday demands interfere with treatment retention and
exploration of creative solutions to such barriers (e.g., flexible clinic
hours, house calls, child care services in outpatient clinics) is an
important direction for future research.
Little is known about the relative merits of treating cocaine abuse in
inpatient versus outpatient settings. The study by Alterman and
coworkers (1994) is the only controlled trial reported to date
examining this topic. While retention rates in that study were
significantly better for inpatient than outpatient care, that advantage
appeared to be offset by the lower frequency at which inpatients
entered aftercare upon discharge. No differences in abstinence rates
were observed between the treatment groups at 7-month followup.
Considering the greater expense of inpatient care, this study provides
no compelling evidence to recommend inpatient over outpatient
settings as a general strategy for treating cocaine abuse, especially
without first exploring less costly options such as the use of
incentives during outpatient care.
37
Relative to psychosocial interventions, less empirical support exists
for the efficacy of pharmacotherapies in retaining cocaine abusers in
treatment. The findings of Gawin and colleagues (1989) and Batki
and coworkers (1994) suggest that there may be patient subgroups or
particular circumstances in which antidepressant therapy can improve
retention in outpatient settings. Patients with comorbid depression,
for example, should benefit from such interventions and thus might be
expected to remain in treatment longer than if they did not receive
such care. However, as far as providing antidepressants to general
clinical samples of cocaine abusers, the preponderance of empirical
evidence suggests that these drugs do not improve retention.
Moreover, at least one trial suggests that fluoxetine can adversely
affect retention (Grabowski et al. 1995). The dose-dependent nature
of that observation suggests that medication side effects may cause
patients to terminate treatment prematurely. A great deal of research
is ongoing to identify effective pharmacotherapies for cocaine abuse.
Thus, avoiding a premature negative position on the potential utility
of medications for retaining cocaine abusers in treatment is
important. The quest for identifying effective new
pharmacotherapies for cocaine abuse and for identifying
circumstances under which existing medications might be more
effective remains an active and important research area.
The ability of an intensive day hospital program to improve aftercare
participation was discussed above (Alterman et al. 1994). The only
other intervention demonstrated to influence aftercare participation
thus far is behavioral treatment with incentives developed by Higgins
and colleagues (Higgins et al. 1993, 1994b). Interestingly, those
effects on aftercare were observed 3 months after the incentive
program had ended, thereby demonstrating enduring effects of that
treatment component. Other aspects of this multicomponent
intervention may improve aftercare participation as well, but that
remains to be demonstrated in controlled trials.
Finally, this review provides further evidence that improved
treatment retention in cocaine abusers generally is associated with
increased cocaine abstinence. That observation is consistent with a
position that drug abuse treatment can be effective, but patients must
be successfully retained so that they receive the recommended
services. As was noted above, equally plausible alternative reasons for
that relationship also exist. Clearly, much remains to be learned
about how to improve treatment retention and how doing so affects
other outcome measures, but this review illustrates that significant
38
inroads have been made in addressing each of the three major
problems of attrition in cocaine abusers.
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J.R.; Kolar, A.F.; and Jaffe, J.H. Comparison of
amantadone and desipramine combined with
psychotherapy for treatment of cocaine dependence. Am
J Drug Alcohol Abuse 17:137-152, 1991.
Wells, E.A.; Peterson, P.L.; Gainey, R.R.; Hawkins, J.D.; and Catalano,
R.F. Outpatient treatment for cocaine abuse: A controlled
comparison of relapse prevention and twelve-step
approaches. Am J Drug Alcohol Abuse 20:1-17, 1994.
Woody, G.; O'Hare, K.; Mintz, J.; and O'Brien, C. Rapid intake: A method
for increasing retention rate of heroin addicts seeking
methadone treatment. Compr Psychiatry 16:165-169,
1975.
42
AUTHORS
Stephen T. Higgins, Ph.D.
Human Behavioral Pharmacology Laboratory
Department of Psychiatry
University of Vermont
38 Fletcher Place
Burlington, VT 05401
Alan J. Budney, Ph.D.
Substance Abuse Treatment Center
Department of Psychiatry
University of Vermont
1 South Prospect Street
Burlington, VT 05401
43
Help-Seeking by Substance
Abusers: The Role of Harm
Reduction and Behavioral-Economic
Approaches To Facilitate Treatment
Entry and Retention
G. Alan Marlatt, Jalie A. Tucker, Dennis M. Donovan, and
Rudy E. Vuchinich
Many substance abusers make repeated attempts to quit or control their drug
use. Some attempts involve participation in formal treatment or self-help
groups, but recovery also can occur outside the context of interventions
(Sobell et al. 1991). It is important to determine what promotes helpseeking at some times and not others, and how influences on help-seeking
may differ from influences on recovery (Tucker and Gladsjo 1993). Survey
research has demonstrated that most substance abusers do not enter
substance-focused treatments or self-help groups (Price et al. 1991; Regier et
al. 1993), although those who seek care utilize other medical and mental
health services with higher frequency than do individuals who do not have
substance-related problems (Putnam 1982). The help-seeking problem thus
involves underutilization of substance-focused services and over- or
misutilization of other health and mental health services. Importantly,
interventions aimed strictly at treatment retention cannot address the more
general problem of why so many substance abusers avoid traditional drug
treatment programs, and efforts to increase appropriate care utilization
require knowledge of the help-seeking process.
There are several reasons that the clinical import of understanding the helpseeking process has not been widely recognized in the substance abuse area
and why research is in the very early stages. First, although help-seeking for
medical and other psychological disorders has been studied for decades,
clinical research on substance disorders historically has not been well
integrated into mainstream health-related research, so focal issues have often
diverged in the literatures. Second, the urgent need for effective
interventions for substance disorders has captured most of the research
resources for several decades, and related issues such as help-seeking that
were not specifically tied to interventions have been neglected. Indeed, the
randomized controlled clinical trial, which is the sine qua non of evaluation
research, assumes that treatment effects are not context dependent and
treats the help-seeking process as a nuisance variable because randomization
eliminates concern with how individuals came to seek care (Mechanic 1978;
44
Moos and Finney 1983; Moos et al. 1990; Vuchinich and Tucker, in press).
However, treatment providers do not have the control over treatment
delivery that is implicit in randomization (and in much research on
treatment matching); practically speaking, clients vote with their feet with
respect to selecting interventions and electing to remain in them or not.
Thus, Moos and colleagues (1990) have argued for naturalistic studies of
treatment entry and treatment outcome that evaluate how influences on
help-seeking interact with treatment engagement and the behavior change
process.
Third, dominant disease model views of substance disorders have a singular
view of the help-seeking process that does not promote concern with the
range of variables found to influence help-seeking for other health problems.
This perspective holds that substance abusers will deny or minimize their
problem and will be unmotivated to seek help until their disease reaches an
advanced stage and overwhelming problems accrue in many areas of
functioning (i.e., they hit bottom). Breaking through denial and accepting
substance abuse as the central problem in their lives is considered essential
for help-seeking and successful behavior change, neither of which is held to
occur until late in the disease process. Apart from the use of confrontational
interventions to break down denial, this perspective has little to say about
the help-seeking process. Moreover, it contains circular assumptions about
the role of intrinsic motivation in help-seeking and successful behavior
change (Miller 1985; Pringle 1982) (i.e., only intrinsically motivated
individuals will seek help and change, and those who do not were not
intrinsically motivated). This view is at odds, however, with studies discussed
later that show that entering treatment to reduce substance use is less
common than entering treatment for substance-related problems and that
labeling someone an alcoholic or drug addict has a detrimental, not
facilitative, effect on help-seeking. Treatment participation is not always
essential for successful behavior change, but little is known about what
promotes entry into treatment at some times and not others. Moreover, the
acquired immunodeficiency syndrome (AIDS) epidemic and the need to
modify the drug-injecting practices of substance abusers who have little
interest in stopping substance use also have made salient the need to
understand factors that deter interactions with traditional treatment
programs and that may promote interactions with low-threshold harmreduction interventions (e.g., needle-exchange programs).
The following section summarizes research on help-seeking for substance
disorders (also see reviews by Hartnoll 1992; Jordan and Oei 1989), which is
a relatively new development compared to research on help-seeking for
health and other psychological disorders (reviewed by Cockerham 1983;
Mechanic 1978). This work has been guided by the health belief
45
(Rosenstock 1966) and related service utilization (e.g., Aday and Anderson
1974) models, which emphasize the interactive influence of barriers and
incentives that are structural (e.g., economic, geographic factors) or
functional (e.g., social influences, dysfunctions in daily living) in nature.
Help-seeking for medical and mental health problems is more strongly
related to functional than to structural variables and, as described in the
following section, help-seeking for substance disorders shows similar
relationships. In the next major section, interventions to facilitate referral
and treatment entry are reviewed, including outreach programs, reducing
waiting time for treatment access, role induction and preparation for
treatment, case management, and motivational enhancement. Final sections
discuss harm reduction and behavior-economic approaches as possible ways
to facilitate treatment entry and retention.
CORRELATES OF HELP-SEEKING
These studies evaluated general associations between help-seeking status
(treated versus untreated) and demographic, substance use, psychosocial, and
health variables. Studies that lacked an untreated comparison group are not
emphasized because of the problems that this creates for data interpretation.
Demographic Characteristics
Few significant demographic differences have been found in studies that
compared treated and untreated opiate addicts or polydrug abusers who used
opiates (Brunswick 1979; Graeven and Graeven 1983; O'Donnell et al. 1976;
Power et al. 1992a; Rounsaville and Kleber 1985), cocaine abusers (Carroll
and Rounsaville 1992; Castro et al. 1992; Chitwood and Morningstar 1985),
and drug abusers with unspecified or highly variable drug histories (Keil et al.
1982; Morrison and Plant 1990). When differences were observed, they
often suggested poorer functioning among treated than untreated subjects
(e.g., Brunswick 1979; Castro et al. 1992; Graeven and Graeven 1983; Keil
et al. 1982). Studies of treated and untreated problem drinkers (Bannenberg
et al. 1992; Coney 1977; George and Tucker, in press; Hingson et al. 1982;
Tucker 1995; Tucker and Gladsjo 1993; Weisner 1993) similarly observed
few demographic differences, with the possible exception that women
problem drinkers tend to be proportionately underrepresented in treatment
samples (but also see Allen 1994; Room 1989).
The lack of robust relationships could be due in part to sampling problems;
for example, some studies used the snowball method of recruitment and/or
recruited treated and untreated subjects using different methods, and few
included large or representative samples of relevant subgroups. However, the
46
pattern of positive and negative findings did not appear to vary
systematically with these methodological features, and the lack of robust
demographic differences is consistent with the broader health-related
literature on help-seeking.
Substance Use Variables
The partition made in most diagnostic schemes between substance use and
substance-related problems (e.g., McLellan et al. 1981) has proven relevant
to help-seeking, because substance-related problems, but not substance use
practices, have been consistently associated with treatment seeking. Studies
of opiate addicts or polydrug abusers who used opiates either found no
relationship between help-seeking status and opiate use (Power et al. 1992a;
Rounsaville and Kleber 1985) or found higher opiate use among treated
subjects (Brunswick 1979; Graeven and Graeven 1983; O'Donnell et al.
1976). Studies of cocaine abusers similarly showed either no differences in
cocaine use (Carroll and Rounsaville 1992) or higher use among treated
subjects (Castro et al. 1992; Chitwood and Morningstar 1985). The same
relationships have been observed in studies with problem drinkers
(Bannenberg et al. 1992; George and Tucker, in press; Hingson et al. 1980,
1982; Timko et al. 1993; Tucker 1995; Tucker and Gladsjo 1993; Weisner
1993).
Studies that assessed drug use other than the primary drug of abuse suggest
that greater other drug use is associated with help-seeking when the primary
drug of abuse is alcohol (Bannenberg et al. 1992; Brown et al. 1994; Tucker
and Gladsjo 1993). The findings were more variable when the primary drug
of abuse was an illicit substance, and several studies observed greater other
drug use among untreated opiate or cocaine abusers (Brunswick 1979
(females only); Carroll and Rounsaville 1992; Graeven and Graeven 1983;
Rounsaville and Kleber 1985). This suggests that the role of other drug use
in help-seeking may depend on whether the primary drug of abuse is legal.
Additional drug use by illicit drug users may not promote help-seeking to the
same degree that illicit drug use does for problem drinkers.
Psychosocial Problems Related to Substance Misuse
Positive associations have been consistently observed between help-seeking
and psychosocial problems related to substance misuse, and more robust
relationships have been found for psychosocial than for demographic and
substance use variables in studies that assessed all three variable classes. This
general pattern has been found across studies of treated and untreated opiate
(Graeven and Graeven 1983; Power et al. 1992a; Rounsaville and Kleber
1985), cocaine (Carroll and Rounsaville 1992; Chitwood and Morningstar
47
1985), polydrug (Morrison and Plant 1990), and alcohol (Bannenberg et al.
1992; George and Tucker, in press; Hingson et al. 1982; Tucker 1995;
Tucker and Gladsjo 1993; Weisner 1993) abusers. In addition, uncontrolled
descriptive studies that only included treated subjects found results suggesting
that treatment entry was associated with increased psychosocial problems
among opiate (Oppenheimer et al. 1988; Sheehan et al. 1986), cocaine
(Brooke et al. 1992), marijuana (Stephens et al. 1993), and alcohol (Thom
1986, 1987; Weisner 1990a) abusers.
For example, Rounsaville and Kleber's (1985) treated opiate addicts had less
adequate social functioning, more drug-related legal problems, and more
depressive symptoms than did untreated addicts, but the groups did not differ
substantially in their drug use patterns or demographic characteristics. Power
and colleagues (1992a) found treated and untreated opiate addicts to be
distinguished primarily by psychological, health, and financial problems
(treated > untreated), whereas demographic and most drug use variables did
not discriminate the groups. Studies with cocaine (Chitwood and
Morningstar 1985), alcohol (e.g., Bannenberg et al. 1992; Tucker 1995;
Tucker and Gladsjo 1993), and polydrug (Morrison and Plant 1990) abusers
found similar results. The only exception was Carroll and Rounsaville
(1992), who found greater legal problems, less adequate social functioning,
and more polydrug abuse among untreated than treated cocaine abusers.
Nevertheless, their treated subjects reported more cocaine-related problems
with family and friends and at work.
Conclusions
These data strongly implicate psychosocial problems related to substance use
in promoting help-seeking, whereas substance use patterns and demographic
variables are not consistently related. This pattern emerged across studies
that were highly variable in sampling procedures, measurement practices, and
data analytic techniques. The association between help-seeking and
psychosocial problems appears robust across drug classes, and the pattern of
results is very similar to that found for other medical and psychological
problems. This suggests that the variables controlling help-seeking for
substance disorders are not fundamentally different from those controlling
help-seeking for other health problems.
COMPONENTS OF THE HELP-SEEKING PROCESS
Despite the global associations observed between help-seeking and
psychosocial problems, the above-mentioned studies do not elucidate the
process by which such problems influenced decisions to seek care. Studies
48
that investigated components of the help-seeking process are selectively
summarized next. These descriptive, largely uncontrolled studies further
implicate psychosocial problems in promoting help-seeking.
Self-Recognition of Substance-Related Problems
Self recognition of substance-related problems has been associated with
heavy (e.g., near daily) substance use and increased negative consequences
(Hingson et al. 1980, 1982; Lorch and Dukes 1989; Skinner et al. 1982). In
addition, studies conducted with alcoholics in treatment and/or Alcoholics
Anonymous (AA) (Orford and Hawker 1974; Park 1973; Park and
Whitehead 1973; Pokorny et al. 1981) indicated that alcohol treatment
entry occurred quite late in the development of alcohol problems and that
seeking medical care typically preceded treatment or AA attendance. Studies
that included more representative samples of problem drinkers (Bucholz et
al. 1992; Room 1989) and drug abusers (Price et al. 1991) similarly found
alcohol or drug treatment to be preceded by contact with a health care
professional. Thus, primary medical care settings may be early contact
points for problem identification and possible referral.
These developmental sequences, however, may not be shared by untreated,
minimally treated, or less severely impaired substance abusers. For example,
this pattern does not appear to hold for adolescents. Lorch and Dukes
(1989) found that most adolescents, including very heavy drug users, did not
consider themselves to have a drug problem, although problem recognition
was related to frequent engagement in burglary. Benson (1990) found that
adolescents were most likely to express willingness to seek help for a drug
problem from an adult friend and then a parent. Adolescents' drug problems
thus appear more likely to surface in social and legal than in health care
settings.
Room's (1989) national survey of adult drinking and help-seeking practices is
especially noteworthy because it systematically assessed the role of the social
network in problem recognition and help-seeking. Receipt of treatment
typically was preceded by informal social controls; before entering
treatment, most problem drinkers first experienced social pressure to cut
down on drinking and then informally discussed their drinking problem with
someone (a family member, friend, doctor, or co-worker, in that order).
Studies of the help-seeking practices of family members of substance abusers
similarly implicated the social network (Corrigan 1974; Gorman and Rooney
1979; Jackson and Kogan 1963; Sisson and Azrin 1986; cf. Finlay 1966).
For example, Sisson and Azrin (1986) reported a successful behavioral
intervention with family members (primarily wives) that reduced physical
abuse to them and facilitated treatment entry by their alcoholic spouses.
49
These studies suggest that there is some sort of self-recognition process that
is tied to increasing substance use (especially daily use) and to substancerelated problems, but recognition does not inevitably lead to help-seeking.
Treatment entry appears to occur late in the development of substance use
problems, although further research on sequencing effects is needed. It is
better established that treatment entry often is preceded by social pressure to
reduce substance use and by informal discussions with social network
members or health care professionals. Expanding their involvement may
facilitate appropriate help-seeking and may reach substance abusers who
avoid traditional intensive treatments.
Barriers to and Incentives for Help-Seeking
Problem recognition probably entails some consideration of helping
resources and the barriers to and incentives for their use. Studies of
incentives for treatment using treated problem drinkers (Beckman and
Amaro 1986; Thom 1986, 1987) indicated that psychosocial (especially
interpersonal) problems were primary motives, more so than a desire to
reduce drinking. However, because most substance abusers do not seek help,
certain studies are especially pertinent to understanding barriers to helpseeking, notably those that included untreated drug (Carroll and Rounsaville
1992; Klingemann 1991; Rounsaville and Kleber 1985) and/or alcohol
(Cunningham et al. 1993; George and Tucker, in press; Tucker 1995)
abusers, either solely or in comparison with treated subjects.
For example, Cunningham and colleagues (1993) found that alcohol and drug
(primarily cocaine) abusers who entered treatment cited similar barriers that
reflected embarrassment or pride, not wanting to share problems, and the
stigmatizing effects of treatment. Untreated substance abusers cited similar
barriers, but their negative attitudes towards treatment and concerns about
labeling were even more pronounced; many also indicated that they did not
perceive that their problem required treatment or they wanted to handle it
on their own. Monetary cost was not a widely mentioned deterrent. Tucker
(1995) and George and Tucker (in press) obtained similar results using
problem drinkers with different help-seeking histories. Also, Klingemann
(1991) found that untreated recovered heroin addicts and problem drinkers
cited barriers reflecting pride in quitting on their own, or they were critical of
current treatments; relative to problem drinkers, heroin addicts were more
likely to lack information about treatment options. Carroll and Rounsaville
(1992) and Rounsaville and Kleber (1985) reported that untreated substance
abusers (cocaine and opiate abusers, respectively) cited as deterrents their
belief that their substance use was under control and that treatment was not
needed. About half of Rounsaville and Kleber's opiate addicts also indicated
50
that methadone maintenance treatment would "make their addiction worse"
(p. 1076).
Role of Event Occurrences in Help-Seeking
Several studies investigated whether events reflecting substance-related
problems preceded discrete help-seeking episodes by drug abusers (Brooke et
al. 1992; Oppenheimer et al. 1988; Power et al. 1992b) and problem
drinkers (Bardsley and Beckman 1988; George and Tucker, in press; Weisner
1990a, 1990b). Most studies found increased negative events, especially
substance-related events, to precede treatment entry. However, only a few
included an untreated comparison group, which is necessary to establish that
patterns of events were uniquely associated with help-seeking and were not
common occurrences in the lives of substance abusers.
A recent study (George and Tucker, in press) that included both treated and
untreated problem drinkers and assessed events over a lengthy (2 year)
pretreatment interval failed to find group differences. Instead, all groups
reported increased events over the assessment period, which was suggestive
of a memory-recency effect. Thus, further research that includes an
untreated comparison group is needed to clarify the role of events in discrete
help-seeking episodes. Although distinct patterns of event occurrences have
been found to precede and maintain stable recoveries achieved with and
without interventions (Klingemann 1991; Tucker et al. 1994, 1995), the
role of events in help-seeking patterns remains uncertain.
Coercive Elements in Help-Seeking
Although court-ordered treatment has become increasingly common,
traditional views of the essential role of client motivation in help-seeking
and behavior change imply that coerced clients are more likely to have poor
outcomes compared to volunteers (Pringle 1982). However, studies that
compared treatment participation and outcomes among coerced and
voluntary clients found similar outcomes across groups and reduced attrition
among coerced clients (see reviews by De Leon 1988; Stitzer and McCaul
1987; Weisner 1990c). Although this suggests that coerced clients may
require relatively more treatment to attain similar outcomes to volunteers
(De Leon 1988), little evidence exists to support traditional notions that
only intrinsically motivated clients benefit from interventions (cf. Miller
1985). In addition, Stitzer and McCaul (1987) argued that the potential of
coercion to promote treatment participation and behavior change may be
underestimated; many studies that evaluated legal coercion did not enact
optimal contingencies between treatment participation and legal
51
consequences, or they did not implement empirically supported
interventions.
However, because some negative consequences of coercion have been
reported (Institute of Medicine 1990), when coercion is used to promote
help-seeking, the least restrictive alternative that will satisfy a client's needs
should be the intervention of choice (Weisner 1990c).
52
Summary Concerning Help-Seeking
Both correlational and process-oriented studies implicate psychosocial
problems related to substance use in motivating help-seeking, although it is
unclear whether discrete events reflecting such problems typically precede
help-seeking or whether an accumulation of problems over time is more
typical. Many substance abusers enter treatment primarily to address these
problems rather than to reduce substance use. Most treatment programs,
however, emphasize abstinence and are not problem-focused, which may
contribute to many substance abusers’ avoiding them.
In contrast to traditional notions that emphasize the importance of intrinsic
motivation for help-seeking and behavior change, extrinsic influences (e.g.,
family, social, and job problems) provide a great deal of the incentive for
help-seeking. Also contrary to traditional notions, recognizing substancerelated problems and desiring to change them do not necessarily entail
acceptance of labels such as "alcoholic" or "drug addict," nor does problem
recognition inevitably lead to help-seeking. Many individuals with substance
disorders reject such labels and recover without interventions (Sobell et al.
1991). Conversely, although substance abusers may participate in
nontraditional interventions, such as community-based needle-exchange
programs, they may come to seek medical or drug treatment through such
gateways (Carvell and Hart 1990).
Process-oriented studies further suggest that informal social networks
influence help-seeking patterns and that few substance abusers enter
treatment without having experienced network messages to seek help.
Among adults, treatment entry also is often preceded by discussion of
substance-related problems with a health care professional. The frequent
reticence of substance abusers to seek help, especially from formal treatment
programs, seems to be rooted not in denial of their substance-related
problems, but in concerns about privacy, labeling, and the stigmatizing
effects of current treatments. Structural factors such as treatment cost and
accessibility are less influential.
53
INTERVENTIONS TO FACILITATE REFERRAL AND TREATMENT ENTRY
Seeking treatment does not necessarily imply that an individual will
successfully engage in treatment (Stark 1992). A very large number of
individuals fail to appear for initial intake appointments; many drop out
after only a brief period (e.g., Stark 1992; Stark and Campbell 1988). Based
on patterns of perceived motivators for or barriers to treatment, researchers
have proposed several interventions to increase treatment entry (Brooke et
al. 1992; Kleyn and Lake 1990; Miller 1985; Oppenheimer et al. 1988).
These clinical efforts may be directed at either helping individuals become
more aware of their problems and consider a need to change (e.g.,
"restorative" strategies) or solidifying readiness to change among those with
problem awareness and translating this among help-seekers into solidified
motivation for treatment entry and compliance (e.g., "consummation"
strategies) (Fiorentine and Anglin 1994). A number of interventions have
been introduced in an attempt to increase treatment entry, but many have
not been fully evaluated.
Outreach Efforts
The traditional view that the client needs to be motivated to change before
interventions shall be provided has led many agencies to be reactive, waiting
for the drug user to approach them for care (Hartnoll 1992). However, this
philosophy has begun to change in a more proactive direction with increased
concerns about the risk of human immunodeficiency virus (HIV) infection
and transmission among drug users (Stimson et al. 1994). An important
factor in attempting to facilitate help-seeking is presenting interventions
that are low threshold, easily accessible, nonthreatening, and that have no
attached stigma. To reduce perceived barriers, changes must be made in
traditional aspects of treatment, including the type of services available and
how and where treatment is offered (Cunningham et al. 1993), and services
should be responsive to the heterogeneous needs of potential clients by
providing a broad range of intervention approaches (Oppenheimer et al.
1988). This might involve moving treatment services from standard agency
settings to be closer to prospective clientele. Examples of such moves
include the methadone by bus project (Buning et al. 1990), in which
methadone doses are delivered to clients on the streets (eliminating the need
for clinic attendance), or the provision of vouchers redeemable for free and
immediate treatment (Levine 1991). The use of such vouchers appears to be
particularly effective in attracting into treatment those intravenous (IV)
drug users who have had no previous treatment exposure (Sorensen et al.
1993).
54
Another example of outreach is the development of needle-exchange
programs for IV drug users. Needle exchanges have developed within the
framework of so-called harm reduction or minimization models (Brettle
1991), which are based on two fundamental principles (Springer 1991).
First, preventing the spread of HIV and AIDS has greater priority than the
prevention of drug use or abuse. Second, abstinence from drugs is not the
only goal of treatment agencies. The purpose of such programs is to provide
clean needles or instructions on how to clean injection equipment to reduce
needle sharing among IV drug users, thus reducing the likelihood of the spread
of HIV among this high-risk group. No explicit focus is placed on stopping
drug use. Despite the potential public health benefits (Clark and Corbett
1993; Des Jarlais 1995), many have objected to needle exchange and other
harm-reduction approaches as going against the more traditional goals of
getting drug users to abstain. There has also been concern that such
programs condone and thus may promote drug use (DuPont and Voth 1995).
However, needle-exchange programs do not appear to be associated with
increased drug use or needle sharing among drug users, or increased initiation
of non-IV drug users into injecting (Guydish et al. 1993). Rather, consistent
with the intended program goals, attendees at needle-exchange programs
typically demonstrate a reduction in drug use, needle sharing, and unsafe
sexual practices (Frischer and Elliot 1993).
Although not explicitly intended to move drug users toward treatment,
needle-exchange programs bring services to otherwise unreached groups
(Grund et al. 1992) and may serve as a precursor to treatment entry (Carvell
and Hart 1990; Clark and Corbett 1993). In addition to reducing barriers to
treatment entry, such programs provide counseling and preventive health
and drug education that may facilitate drug users’ consideration of treatment
as an option (Brettle 1991). Carvell and Hart (1990), for example, found
that more than one-third (38 percent) of clients in a needle-exchange
program accepted referrals to drug treatment or medical/health-related
agencies. Those accepting referrals had begun initial opiate use, injecting,
and daily injecting at an earlier age, and also were more likely to indicate
that they were seeking help compared to those not receiving an onward
referral. Carvell and Hart (1990) suggest that low-threshold outreach
programs that have open-access policies, attempt to attract clients not in
contact with traditional treatment agencies, and promote a harm-reduction
focus can serve as gateways to other services.
Reduced Waiting Time
Health and social service research suggests that treatment program
characteristics may affect treatment entry in a number of ways. Miller
(1985) suggested that relatively straightforward environmental interventions
55
that reduce program barriers can improve individual motivation for
treatment. Of the different program variables potentially affecting drug
treatment entry, only waiting time has received much study. Free treatment
that is available on demand has been advocated by harm-reduction
proponents as a means of facilitating treatment entry (Carvell and Hart
1990; Hartnoll 1992; Springer 1991). However, because limited treatment
slots and few alternative treatment approaches are available in many public
agencies due to restricted funding, decreased treatment availability often
translates into increased waiting times (Anonymous 1990).
Efforts to decrease waiting time have been questioned by some (Addenbrooke
and Rathod 1990) on the grounds that making it easier for people to get into
treatment may reduce treatment retention. On the other side, advocates of
reducing waiting time note that many people who apply for treatment are
often ambivalent about stopping drug use, have unstable lives, and may
interpret waiting time to mean that the treatment program is not prepared
to help them and thus may decide to address their problems elsewhere or to
continue their drug use (Brown et al. 1989; Stark et al. 1990). Shorter
waiting times between a drug abuser’s receipt of a referral or an initial phone
contact with a clinic and the initial intake appointment appear to be
associated with an increased likelihood of appearing for the initial
appointment and a trend toward slightly longer treatment participation
(Addenbrooke and Rathod 1990). Longer waits appear to be associated with
a decreased interest in entering treatment and with significant increases in
legal involvement, incarceration, family separation, and rates of death
(Brown et al. 1989; Patch et al. 1973).
For example, in one study (Stark et al. 1990), drug users who requested entry
into an outpatient community treatment agency were randomly assigned to
receive either an appointment in the next 2 weeks or to come as soon as
possible to begin the intake process. Those who were asked to come the
same day they called appeared at the clinic at a significantly higher rate (60
percent) than those who were given a delayed appointment (38 percent).
Similarly, Festinger and associates (1995) found that the number of days
between the initial phone contact and scheduled intake appointment was the
only variable among a number of client and clinic characteristics to predict
whether cocaine abusers attended their initial appointment. The greatest
decrease in initial attendance occurred in the first 24 hours following the
phone inquiry. Such findings suggest that changes in program barriers such as
waiting time may be easier to implement and have more impact on
facilitating treatment entry than attempting to change client characteristics
(Festinger et al. 1995; Miller 1985).
56
If treatment entry cannot be expedited, providing support while clients wait
may be an important interim step. Brown and colleagues (1989) found that
65 percent of drug abusers who were waiting for a bed in a residential drug
treatment program indicated interest in attending a once- weekly group
counseling program until they could be admitted. Such pretreatment groups
can provide support, a cost-effective orientation to treatment, and
therapeutically focused time structure while clients await more formal or
intensive therapy (Brekke 1989). Such programs also may increase
treatment entry, treatment compliance and completion, and/or involvement
in aftercare (Conti and Verinis 1989; Olkin and Lemle 1984; Ravndal and
Vaglum 1992), although such positive effects have not been reported
consistently (Alterman et al. 1994).
ROLE INDUCTION
Several studies evaluated the effectiveness of using role-induction techniques
to increase retention of drug-abusing clients early in treatment, and Ravndal
and Vaglum (1992) suggested that the pretreatment intake groups discussed
above should be developed as role-induction strategies in which clients learn
coping skills to help them adjust to treatment. These approaches have
evolved out of the general psychotherapy literature, where client
misperceptions and lack of agreement between client and therapist about
important features of therapy (e.g., length of treatment, client-therapist
roles) have contributed to premature dropout (Zweben and Li 1981). These
interventions attempt to promote treatment engagement by reducing
confusion, clarifying expectations and roles, and providing the client with a
better understanding of the treatment process. Such efforts appear
particularly appropriate for drug abusers because many who seek treatment
have no previous treatment experience and often express numerous fears
(e.g., their knowledge is limited about the treatment process generally, or
about the specific agency or treatment to which they had been assigned; they
worry about not getting treatment that matches their needs or expectations;
they are concerned about not having their problems understood, or they fear
failing in treatment) (Cunningham et al. 1993; Oppenheimer et al. 1988;
Sheehan et al. 1986).
Support for the use of role induction with substance abusers is mixed. Stark
and colleagues (1990) evaluated a brief role-induction intervention presented
when drug abusers contacted a clinic. Clients who received the intervention
were asked about potential barriers to attendance, and an attempt was made
to help resolve them. At the end of 1 month, however, only 11.1 percent
of the sample were active clients, indicating that a brief discussion about
barriers to treatment was insufficient to overcome the barriers or to increase
57
clients’ commitment to treatment. Zweben and Li (1981) evaluated a single
group session of role induction prior to treatment in an outpatient substance
abuse clinic. Clients who participated in one of three different role-induction
conditions were somewhat (although not significantly) more likely (54.4
percent) to remain for the initial four sessions of treatment than were those
in the control group (34.6 percent). An interaction between the type of
induction procedure and the match between clients' and staff's beliefs about
treatment suggested that role induction may be particularly effective in
reinforcing the expectations of clients who are already relatively
knowledgeable about treatment, more so than in reducing discrepancies
among clients who hold less accurate expectations. This process might be
facilitated further by use of ex-clients who share first-hand experiences about
the treatment process and serve as role models of individuals for whom
treatment was effective.
Treatment-specific role induction appears to be more effective than
interventions focusing on either more general psychotherapeutic issues or on
general drug information (Stark and Kane 1985). Of clients assigned to the
drug treatment-specific role-induction condition, 91 percent returned at least
once after an initial intake compared to 72 percent, 61 percent, and 5
percent of those who received general psychotherapy information, drug
information, or no information, respectively. However, the percentage of
clients who remained active in treatment 3 months later did not differ across
conditions. Finally, Siegal and colleagues (1993) developed a weekend-long
treatment-induction process. Although the program’s efficacy has not been
evaluated, such an intensive introduction to treatment may increase
compliance and be more useful for reducing discrepancies among less
informed clients than Zweben and Li (1981) were able to induce in a singlesession intervention.
Case Management
Role-induction approaches, while showing some promise in increasing
treatment entry, appear to be insufficient to maintain a high rate of
continued involvement. Those entering treatment have more concerns
about and perceive a greater need for help with problems in a wide range of
life areas (Power et al. 1992a). Furthermore, data on beliefs about treatment
suggest that many clients expect treatment programs to provide access to
other health and social support services (Brooke et al. 1992; Thom 1986),
which is the goal of case management approaches. Although case
management is more commonly employed as part of active treatment or
aftercare, these services also have been used in assessment and referral
centers to try to facilitate treatment entry (Graham and Timney 1990;
Ogborne and Rush 1990; Timney and Graham 1989). They may also be used
58
to solidify the gains made in treatment readiness brought about through roleinduction approaches (Siegal et al. 1993). Case management functions
ordinarily include assessment of service needs, planning, linking, and
monitoring service delivery. They can also include client advocacy, delivery
of therapeutic services, and community activism (Graham and Timney
1990). The development of linkages to community services can help
remove barriers to treatment that homelessness, physical or mental illness,
or other problems can create (Cook 1992; Willenbring et al. 1991).
Case management has not only involved linking clients with ancillary
services, but with treatment as well. In a study by Bokos and associates
(1992), drug injectors who sought publicly funded treatment were assigned
to a case manager (who conducted an assessment, facilitated treatment
entry, and addressed other immediate needs) and were compared with
controls (who were given the names, addresses, and phone numbers of
three treatment clinics). Ninety percent of the case- managed group
entered treatment compared to only 35 percent in the control group.
Average time to admission for case-managed clients was 6.2 days
compared to 31.7 days for controls. Similarly, transitional case
management for street-based drug injectors not in treatment, involving
referrals for services based on an individualized needs assessment and
services, resulted in the receipt of more concrete help and greater entry
into alcohol and drug abuse treatment services than did standard referral
procedures (Lidz et al. 1992).
Further research is needed to evaluate the efficacy of case management
approaches in aiding treatment entry and compliance. Case management
used to enhance treatment entry has been limited in scope and duration,
which appears appropriate as it may not be cost effective to provide
overly intensive services to clients who have not fully committed to
treatment (Stark et al. 1990). However, modifications may be required in
the case management methods to maximize their use at the point of
treatment entry (Bachrach 1993).
Motivational Interventions
Miller (1985) identified a number of motivational interventions to
increase the probability of substance abusers' entering and continuing in
treatment and otherwise complying with an active change strategy.
Specific components identified across successful motivational
interventions (Miller 1989; Miller and Rollnick 1991) include: (1)
providing feedback from assessments concerning the impact of substance
use on physical, social, and psychological functioning; (2) providing direct
advice about the need for change and how it may be accomplished; (3)
attempting to remove significant barriers to change; (4) suggesting or
59
providing alternative approaches from which the individual can choose to
achieve change; (5) decreasing the attractiveness of substance use through
increasing awareness of the negative consequences and risks associated
with it; (6) utilizing external contingencies or pressures to enhance
commitment; and (7) developing a clear set of personal goals for change
and maintaining periodic contact. In using each of these components, the
desired outcome is to increase the individual's commitment to and
motivation for change (DiClemente 1991).
Interventions based on these motivational principles have been shown to
facilitate referral for and continuation in alcohol treatment (Bien et al.
1993; Zweben et al. 1988); they have also been applied to drug users
(Saunders et al. 1991; van Bilsen 1991, 1994), although motivational
interventions used to encourage drug treatment entry have varied in
approach and outcome. Saunders and colleagues (1991), for example,
described a two-session motivational intervention used with heroin addicts
who were beginning methadone maintenance that appeared to incorporate
the general principles described by Miller (1989; Miller and Rollnick
1991) as well as specific interventions derived from identified
components in the self-change process among drug users. As an example,
clients were assisted in reviewing the benefits and negative consequences
associated with using heroin and other drugs, evaluating their level of
satisfaction with their current lifestyle, elaborating their current concerns
(especially those identified as causing the most emotional distress),
engaging in a decisional balance of weighing the costs and benefits of
continuing drug use or changing this behavior, and establishing some
future-oriented goals for changing drug use. Allsop and Saunders (1991)
employed a similar approach in dealing with severely dependent
alcoholics to develop what they described as robust resolutions.
Conclusions
Treatment entry is only one of many steps in the behavior change
process. More research is needed to extend the application and evaluate
the utility of each of the interventions reviewed above. Stark and
associates (1990) suggested that regardless of demographic status,
personality traits, and drug of choice, the majority of substance abusers
who seek treatment will have difficulty continuing or completing it (see
Stark 1992 for a more thorough review of variables influencing dropping
out of treatment). While holding promise, interventions to date have had
limited effectiveness in facilitating treatment involvement much beyond
the entry point. Combinations of the different intervention strategies,
such as role induction and case management (Siegal et al. 1993), may
prove to have a greater impact than any used in isolation. In addition,
60
Stark and Campbell (1988) suggested the development of more specialized
attrition-prevention strategies based on the general principles of Marlatt's
relapse prevention model (Marlatt and Gordon 1985). In such an
approach, circumstances that are associated with dropping out of
treatment would be identified and clients would be assisted in developing
skills to recognize their occurrence and to cope with them more
effectively.
RECOMMENDATIONS TO FACILITATE HELP-SEEKING AND RETENTION
What do these findings suggest about facilitating appropriate helpseeking? First, current treatments that are tied to the health care delivery
system are stigmatizing, and treatment innovations that are delivered
through this system probably will not substantially increase utilization.
Nevertheless, better integration into the health care system of the more
intensive treatments needed by a minority of substance abusers will likely
reduce the stigma somewhat. Furthermore, covering substance-related
treatments in comprehensive medical insurance plans produces well
known cost-offset benefits (Holder and Blose 1992) and probably helps
reduce the misutilization of health services by substance abusers.
Second, less intensive interventions aimed at the majority of substance
abusers who do not meet clinical criteria for dependence probably will
serve more affected persons if they do not have to enter the health care
system as a patient with a substance-related diagnosis. Community-based,
low-threshold interventions would seem to be especially attractive
alternatives. However, AA, Narcotics Anonymous (NA), Cocaine
Anonymous (CA), and related groups that share a 12-step philosophy
currently are the only widely available community-based interventions.
Because their appeal is not universal, additional community-based
interventions are needed (e.g., Rational Recovery, Women for Sobriety,
Secular Organization for Sobriety, Moderation Management).
Third, health care professionals in primary care settings could be more
effective referral agents if they had a broader range of assessment and
intervention alternatives to offer patients with a possible substance
disorder. For example, being able to offer an evaluation opportunity that
is not an inevitable precursor to extended treatment (such as the Drinker's
Check-Up, Miller and Sovereign 1989) would be preferable to referring
patients to treatment and/or self-help groups regardless of problem
severity.
61
If one were to consider designing an ideal program based on the foregoing
review of issues related to help-seeking and treatment entry for substance
abuse problems, what can be recommended? Overall, the goals of such a
program would include reducing the stigma of the problem, providing lowthreshold access to treatment options, integrating prevention and
treatment services for both substance abuse and mental health problems,
matching programs to individuals based on both professional advice and
consumer choice, and providing ongoing case management and followup
services (including relapse management).
With a primary focus on prevention and health promotion, the stigma of
substance abuse treatment could be substantially reduced. Communitybased programs could be established in schools, worksite settings,
community centers, and primary health care facilities (cf., Institute of
Medicine 1990). The core theme and public image for such programs
would be lifestyle management and habit change. A variety of positive
health habits and high-risk behaviors could be covered, including diet and
exercise; drinking, smoking, and other drug use; and high-risk sexual
behaviors. Programs run by peer-based counselors trained in the
principles of health promotion probably would be more appealing to the
public than professionally led treatment programs for substance abuse.
Combining Behavioral, Harm-Reduction, and Public Health Principles:
The McHabit Center Example
One might consider calling the ideal program the McHabit Center—a onestop center that provides low-threshold access to various health
promotion options. Rather than embracing a disease model of addiction,
the center would be guided by a more comprehensive biopsychosocial
model (Marlatt 1992). Personal responsibility for adopting healthy
lifestyle habits would be emphasized within a psychoeducational approach
that emphasizes learning adaptive coping skills. The atmosphere would
resemble a community college more than a clinic.
Upon arrival at the McHabit Center, students would first be assigned an
advisor who meets with them individually to guide them through the
program offerings. Initial assessment of lifestyle habits could be
accomplished by having students complete a computerized lifestyle
assessment battery (Skinner 1993). After completion of the
computerized assessment and other diagnostic evaluation, the student
meets with the advisor for a session providing feedback, motivational
enhancement, and selection of program goals for lifestyle change. All
students would be assigned to a core course on the principles of habit
change and health promotion. Other courses would deal with specific
62
health habits and would be assigned on the basis of the initial assessment.
Course offerings might include smoking cessation, nutrition and diet,
exercise and relaxation, alcohol and other drug use, changing high-risk
sexual behavior, as well as anger management and assertiveness training.
Most classes would be taught in a group format with many opportunities
for discussion, role-playing, and practicing new behaviors as the main
homework assignment. Instead of receiving grades, students would be
given frequent feedback on their progress based on monthly followup
computerized assessments. Advisors would continue to meet individually
with students periodically to monitor progress and setbacks and to offer
support and guidance. Advisors would also offer referral to primary
health care providers so that there would be access to medications and
other medical services when appropriate.
Although the advisor may recommend specific goals to match the needs
of a particular individual, students/clients will also be asked for their
opinions and preferences for various goals and program options (Krantz
et al. 1980). To increase awareness of different programs, clients would
be encouraged to visit or sit in on various classes to see how they work in
actual practice. Another possibility would be to provide students with a
menu of program alternatives presented in the form of videotaped
segments that portray samples of each program in action. This procedure
combines elements of role induction, treatment matching (in which
advisors recommend specific programs), and consumer choice or client
preference. After the advisor and student agree on a particular choice,
additional role-induction training could be used to further prep the student
prior to the beginning of the program. When professional matching
recommendations are in conflict with the client's own preferences, a
negotiation process would be necessary to select priorities and alternatives
(e.g., if the client selects a program that later proves to be unsuccessful, a
second "backup" program can be introduced). Here the primary aim is to
keep the client engaged throughout the intervention process and to
prevent treatment dropout (attrition prevention).
With prevention and risk reduction as the central themes for working
with substance use behaviors, the center would provide primary,
secondary, and tertiary prevention programs depending on the needs of
the clientele. For those who are assessed to be relatively free of current
drug problems, the emphasis would be on primary prevention and on
helping those who have experimented with initial substance use to
prevent future abuse and dependency problems. For others who have
already had experience with alcohol, smoking, or other drug use, goals
would include both secondary prevention (e.g., to reduce excessive alcohol
consumption) and tertiary prevention (e.g., to prevent relapse in smoking
63
cessation). Prevention programs in general would be guided by a threefold
approach that combines individual self-management training with
enhancing social support and facilitating environmental reinforcement
for behavioral alternatives to substance use.
In this approach, no formal distinction is made between prevention and
treatment programs. Problems including substance abuse are viewed along
a continuum of severity or harm, with no clear demarcation point to
indicate which clients need treatment. In a sense, all programs offered
would represent preventive interventions and would differ only in terms
of the prevention goal. Target behavior change would include both
moderation (secondary prevention) and abstinence (tertiary prevention).
Special relapse prevention classes or groups would be offered to clients
who experience setbacks or lapses in an attempt to keep these individuals
engaged in the intervention process.
The McHabit Center, ideally situated in easily accessible environments
(e.g., shopping malls), would also provide community outreach services to
provide information and assessment opportunities to at-risk groups who
otherwise might be overlooked. For example, outreach programs could
target individuals who are deemed to be at risk based on such factors as age
(e.g., adolescents or the elderly), gender, ethnic status, family history,
living environment, and comorbidity of substance use and psychological
problems. For prospective clients who are interested in knowing more
about prevention and treatment program options, short informational
programs would be offered to teach people about the range of programs
and services available. The center would also accommodate individuals
who are court mandated to receive services. To reduce problems of
noncompliance associated with coerced treatment, such clients would be
mixed in with the voluntary clients rather than treated as a separate
group. Centers could be run on a for-profit basis (similar to commercial
weight-loss or fitness centers) and/or could be supported financially by
existing health maintenance organizations (HMOs) and associated
insurance programs.
The primary assumption guiding both prevention and treatment programs
based on this model is that the person is to be viewed as a unique
individual who is deserving of an integrated approach to his or her life
problems. A client's substance use problems are assessed in the context of
other life problems within a holistic perspective. By using a functional
analysis to assess behaviors targeted for change, the emphasis shifts from
a diagnostic focus (substance abuse or mental illness per se) to assessing
the consequences of maladaptive coping patterns. Clients who use
substances to cope with psychological problems (e.g., drinking in an
64
attempt to cope with depression) are distinguished from those whose life
problems are a consequence of substance abuse. Unlike many
contemporary programs that treat substance abuse separately from other
mental health problems (or vice versa), the McHabit Center would
provide an integrative model that examines the interaction and
complexity of each client's unique lifestyle and problems in living. Such a
center would probably have particular appeal to adolescents and young
adults who are more likely to be motivated by a program that emphasizes
general lifestyle coping and health promotion as compared to traditional
programs that focus exclusively on substance abuse and addictive disease.
How would decisions be made about the intensity and duration of
intervention programs in a center that integrates prevention and
treatment services? Many traditional addiction treatment agencies offer
comprehensive fixed-length programs (e.g., 28-day residential programs).
In these programs, clients are assigned to treatments of fixed duration
based on a one-size-fits-all assumption. Adolescents who show early signs
of substance abuse problems are often treated the same way as older,
chronic users, because they are all assumed to have the same disease that
differs only in terms of whether it is early or late stage. This uniform
disease model implies the same treatment goal for all: total and lifelong
abstinence.
One promising alternative to the one-size-fits-all approach is a steppedcare model (Abrams et al. 1991; Sobell and Sobell 1993). Derived from a
public health perspective, the stepped-care model provides a series of
intervention options that vary in intensity and degree of professional
involvement. Interventions begin with a minimal step or brief
intervention that might prove effective for many clients. Additional
steps of increased intensity are offered only if former (less intensive)
interventions prove ineffective. The stepped-care approach is used with
certain primary health care problems such as the treatment of borderline
hypertension. Here the physician might begin the intervention process
by recommending that the client take the initial step of reducing salt
intake and changing diet to lose weight. Blood pressure is continuously
monitored to evaluate the impact of these changes. If changing dietary
patterns is not sufficient, the client may then be advised to begin a regular
exercise program before blood pressures are again assessed. Additional
steps may then be recommended until the desired blood pressure reduction
is achieved, including prescription of medications. Medication levels are
titrated upwards (from lower doses to higher ones) or other medications
are prescribed until the treatment goal is achieved and the hypertension is
under control.
65
A similar stepped-care model can be applied to working with substance
abuse problems. Here the initial steps could include various self-help
options, such as manuals, books, and computer software programs for
habit change, or membership in a self-help support group. If these steps
are unsuccessful, the client could be stepped up to receive more extended
professional services in the form of classes or groups (as described in the
McHabit Center curriculum). If additional services are required, individual
outpatient counseling could be introduced. Residential treatment would
also be available, but only as a final step if less intensive interventions
continue to be ineffective. Of course, clients could be moved to higher
levels of intensity depending on the severity of the case.
The stepped-care model has recently been successfully applied in a
program designed to reduce alcohol abuse (e.g., binge drinking) in
adolescents and young adults in the college setting (Marlatt et al. 1995).
In this study, high-risk drinkers were randomly assigned to receive either a
stepped-care intervention program or to a no-treatment control group.
Participants who received the stepped-care program first were given a
brief intervention (less than 1 hour) in which each student met
individually with a member of the authors’ staff in the context of a
motivational interview (Miller and Rollnick 1991). The purpose of this
interview was to provide support and motivational enhancement for
reducing harmful drinking levels. Each participant was provided feedback
about his or her drinking levels and associated health risks. Interviewers
adopted an empathic style, supporting any attempts the student reported
having made to reduce risky drinking behavior. Tips for making
additional changes were offered in a nonconfrontational manner. During
followup assessment periods, high-risk participants who received this brief
intervention along with annual feedback reports on their drinking
reported a significant decrease in both drinking rates and associated
harmful consequences over a 3-year period, compared to the notreatment control group (Marlatt et al. 1995).
Although the majority of participants reported significant reductions in
drinking problems after receiving this single session of feedback and
advice, some did not respond and others actually increased drinking rates.
For them, additional program options of greater intensity were offered, in
accordance with the stepped-care model, including group support
meetings, individual counseling, and even a seminar they could take for
credit on the topic of guided habit change. Subjects who showed signs of
severe alcohol problems or dependence were seen individually and
recommended for abstinence-based treatment.
66
The alcohol risk-reduction program described above, along with the
McHabit Center concept, are congruent with a harm-reduction approach
to addictive behavior change (Engelsman 1989; Heather et al. 1993;
Marks 1992; O'Hare et al. 1992). Harm reduction refers to policies and
programs designed to reduce or minimize the harmful consequences of
ongoing addictive behaviors. Needle exchange, discussed in an earlier
section, is a harm-reduction policy designed to reduce the risk of HIV
infection by eliminating the need for addicts to share injection equipment.
Harm reduction embraces a wide variety of previously unrelated programs
and techniques, including methadone maintenance, nicotine replacement
therapy, and safer-sex programs designed to reduce the risk of sexually
transmitted disease (Marlatt and Tapert 1993). Controlled drinking or
moderation training fits well with a harm-reduction framework (Marlatt
et al. 1993).
Harm-reduction programs are designed to be low threshold, removing
barriers to treatment access. One such potential barrier to initial helpseeking may be the requirement of abstinence as a condition of entry into
treatment. Although abstinence is embraced as the distal goal for
substance abuse treatment, harm reduction encourages incremental risk
reduction with an emphasis on attainable proximal goals (e.g., reduced
consumption, safer methods of drug administration).
Programs based on harm-reduction principles are often developed in
collaboration with the target population. As an example, the impetus for
the original development of needle-exchange programs in The
Netherlands came from organized groups of addicts (Engelsman 1989).
Future harm-reduction programs also will benefit from input and
consultation with those who are directly affected. Professionals in the
addictive behaviors field can work cooperatively with people who are
experiencing these problems to facilitate help-seeking and treatment
access. Rather than dictating program requirements and procedures by
administrative directives issued from the top down, harm-reduction
procedures can be developed in partnership with the population most
affected. Through mutual discussion and respect (e.g., in focus groups or
other combined meetings), barriers to help-seeking may be reduced or
eliminated. By having people with addictive behaviors play a greater role
in designing alternative programs and treatment options, the
empowerment they experience as a result will go a long way toward
removing the stigma associated with this problem.
Harm-reduction programs place greater emphasis on input from the
clients seeking services than do most traditional addiction treatment
programs. This perspective puts more onus on the consumer of such
67
programs to become active and responsible in the behavior change
process. One approach that speaks directly to the question of consumer
choice and environmental options is the topic of behavioral economics.
In the concluding section that follows, some preliminary ideas are
presented about how substance abuse treatment might be interpreted
within a framework of behavioral economics.
Behavioral-Economic Theory and its Implications
for Help-Seeking
Traditionally, psychological views of addictive behavior have focused on
internal mediational constructs (e.g., anxiety, tension, self-efficacy)
thought to motivate alcohol and drug consumption. The general practical
implication of this focus has been that if these mediational variables could
be changed, usually as a result of therapy, it would lead to addictive
behavior change. It is now known, however, that contextual
environmental forces outside the psychotherapy situation have powerful
effects on addictive behavior (Moos et al. 1990; Tucker et al. 1995;
Vuchinich and Tucker 1988), and it is difficult to characterize these
contextual variables adequately by incorporating them into internal
mediational constructs (Vuchinich, in press-a; Vuchinich and Tucker, in
press). This presents a need for a fresh perspective with new concepts
and methods, and it is suggested that behavioral economics provides a
potentially useful conceptual framework for understanding the effects of
extratherapeutic variables on addictive behaviors.
Basic behavioral economics originated with a merger of methods from the
experimental analysis of behavior and of concepts from consumer
demand theory in economics (e.g., Rachlin et al. 1981). Instead of
focusing on internal mediational constructs, it relates temporally
extended behavior patterns to molar features of environmental contexts,
which is the level of analysis needed in a broadened psychological
perspective on addictive behavior change. The general goal of behavioral
economics is to understand how scarce resources are allocated to gain
access to a set of valued activities under variable constraints, and it has
been quite successful in improving understanding of environmental
variables that control demand for a variety of commodities (Kagel et al.
1995).
Given that behavioral economics is directly concerned with demand for
commodities, it is readily applicable to the study of addictive behavior
where the fundamental problem is excessive demand and consumption.
Behavioral economics has been successfully applied to studying several
aspects of alcohol and drug abuse (DeGrandpre and Bickel, in press; Green
and Kagel, in press; Vuchinich, in press-b; Vuchinich and Tucker 1988).
68
This work has shown that alcohol and drug consumption is a joint
function of constraints on access to the addictive substance and other
valuable activities that are available and constraints on access to them. In
general, alcohol and drug consumption varies inversely with constraints
on access to alcohol or drugs, and varies directly with constraints on
access to valuable alternative activities. This is consistent with the basic
tenet of behavioral economics: Demand for any commodity is a function
of the economic context (e.g., the price of the commodity of interest,
other available commodities and their price, income) in which it is
available.
Several findings from the help-seeking literature reviewed earlier can be
interpreted from a behavioral-economic perspective. A striking feature
of the data on help-seeking for substance abuse is that only a small
minority of abusers seek treatment, even though it appears to be readily
available at an affordable cost. The behavioral-economic literature on
discounting of delayed and probablistic outcomes (Rachlin et al. 1991)
may be relevant to this issue. It is well known that the value of delayed
and probablistic outcomes, both positive and negative, is discounted to
various degrees, although the shape of the discount function is a matter of
some dispute (Rachlin et al. 1991). Such discounting may be relevant to
help-seeking in that treatment entry places the substance abuser in a
position of foregoing a certain, immediately available, and highly valued
commodity (the abused substance) in order to obtain a probablistic and
delayed outcome (benefits of treatment). Given the value of the abused
substance and the probablistic and/or delay discounting of treatment
benefits, it is perhaps understandable why most substance abusers do not
seek treatment.
The role of discounting delayed and probablistic outcomes may be
especially important with substance abusing populations who may
discount such outcomes at a higher rate than do nonabusers: It is possible
that alcohol and drug abusers engage in excessive consumption partly as a
result of heavily discounting delayed and probablistic outcomes. If so,
then such populations present a doubly difficult problem: They are
substance abusers because they heavily discount the future, and because
they heavily discount the future, they are unlikely to enter treatment.
At least three implications for potentially increasing help-seeking and
treatment retention follow from these speculations. First, these
behaviors might increase if the current demand for immediate and
continuous abstinence during treatment were relaxed to allow some level
of continued consumption of the abused substance. Although this
suggestion is anathema to traditional views, it is consistent with the so-
69
called harm-reduction perspective described earlier and with behavioraleconomic concepts. For whatever reason, consumption of the abused
substance is a highly (if not the most) valued activity of substance abusers.
Demanding immediate and continuous abstinence is therefore taking away
something of high value without replacing it with anything of equal value.
Permitting some continued consumption, at least temporarily, may
increase help-seeking in that the substance abuser would not face the
certain loss of the highly valued abused substance when entering
treatment, and it may provide a buffer period during which alternative
valuable activities could be developed.
Second, help-seeking and treatment retention might be increased if
treatments were more effective, and refined and specialized as discussed in
the previous section. Improved treatment is a valued goal from any
perspective, but it appears to be the case that treatment effectiveness is
rarely if ever cited in the current literature as an important determinant
of help-seeking or staying in treatment. Behavioral economics provides a
sound theoretical reason for a possible relation between treatment
effectiveness and help-seeking and treatment retention: Benefits from
current treatments are far from certain, but if they were better defined,
more probable, and occurred sooner, their value would be discounted less
and treatment would be engaged in more.
Third, and somewhat related to the first two points, treatments should
more quickly and more directly address improving clients' access to valued
activities other than the abused substance. In behavioral economic terms,
facilitating clients' engagement in such valued alternative activities would
provide effective substitutes for substance consumption. As mentioned
above, demand for any commodity, including alcohol or drugs, is a
function of the economic context of its availability. It is well
documented that the ready availability of alternative activities is a critical
aspect of this context in that it has a powerful effect on reducing alcohol
and drug consumption (Carroll, in press; Vuchinich and Tucker 1988).
This issue seems particularly relevant to help-seeking; the literature shows
that individuals seek treatment more because of the life problems caused
by their addictive consumption than because of the addictive consumption
itself. Thus, if treatments focused on these life problems as much or
more than they focus on consumption of the abused substance (Allsop and
Saunders 1991; Cox et al. 1991; Saunders et al. 1991), then treatmentseeking and retention might be increased. Moreover, recent work
(discussed in Carroll, in press) indicates that the ready availability of a
valued alternative reinforcer can block the development of drug selfadministration in animals. This relation may have important prevention
implications given that most substance abusers begin using the abused
70
substance during a relatively brief period in adolescence (Kandel and
Logan 1984). Thus, from a behavioral economic perspective, enriching
the environment with valuable nondrug activities provides a potentially
powerful vehicle to prevent the development of substance abuse, promote
treatment entry, and design more effective interventions.
CONCLUSIONS
The themes presented in this chapter about help-seeking, treatment
retention, and recommended changes in the U.S. substance abuse
treatment delivery system emerged coherently out of highly disparate and
previously unrelated literatures. Whereas in the past the major thrust of
scientific, clinical, and some policy initiatives has been to advance
increasingly more effective treatments for substance disorders, these
recent literatures point in a different direction. It is the authors' view
that currently dominant treatments for substance disorders have probably
reached an asymptote with respect to their effectiveness and range of
applicability. Continued efforts to improve them without attending to
the broader systems and contexts within which they are available are not
likely to prove fruitful or to reach the chronically underserved majority
of substance abusers. Emphasis should thus be shifted towards understanding the broader contexts in which substance disorders emerge and are
maintained and within which help-seeking experiences of many different
forms are encouraged or discouraged. Expanding community involvement
in the management of substance-related problems is a clear priority
(Institute of Medicine 1990).
Understanding and modifying the health care delivery system as it
pertains to substance disorders will be an important piece of this focus
(and there will be many opportunities for modification as health care
reform and managed care initiatives evolve). In the authors’ view,
however, interventions tied exclusively to the health care system have
been and will likely continue to be insufficient, even if the particulars of
treatment programs are revised and more treatment slots become
available. This is true because treatments made available through this
system are stigmatizing (Cunningham et al. 1993; Tucker 1995), and, as
concluded by Weisner and colleagues (1995) in a review of trends in the
U.S. alcohol treatment delivery system during the past decade, "[I]t is
clear that simply achieving increased treatment capacity does not
necessarily result in changes in utilization patterns" (p. 59). Changing
utilization patterns in a positive way will depend on improved
understanding of contextual influences on help-seeking patterns and on
71
increased availability of alternative, low-threshold interventions in the
community.
This shift in perspective and resource allocation has been occurring during
the past 10 to 15 years in several European countries with some initial
success, but it has been slow to develop in the United States (Hartnoll
1995). One can only speculate why this is the case, but several reasons
come to mind. First, relative to the insurance-based health care system in
the United States, for some time European systems have been organized
in a more socialized fashion around primary care physicians who serve as
system gatekeepers; this has probably contributed to differing sensitivities
to the role of the health care system in promoting or deterring health
care delivery, which is more widely acknowledged and researched in
Europe. Second, in the United States, the for-profit substance abuse
treatment delivery system typically is based on a medical staffing
arrangement (including a responsible physician along with nurses and
other subdoctoral staff including certified substance abuse counselors) that
is economical and efficient, but it has retarded the involvement of other
professionals and minimized the influence of alternative views of
behavior change that lie outside the purview of medicine. Third, in the
United States, many more Federal dollars have been allocated to reducing
drug availability through interdiction, while demand-side approaches that
emphasize prevention and treatment have been relatively neglected.
Behavioral-economic theory points to the potential utility of demandside interventions that enrich the environments of substance abusers by
providing nondrug alternative activities that compete with drug use.
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83
AUTHORS
G. Alan Marlatt, Ph.D.
Professor of Psychology
University of Washington
Department of Psychology, Box 351525
Seattle, WA 98195-1525
Jalie A. Tucker, Ph.D.
Professor of Psychology
Auburn Universisty
Department of Psychology
226 Thach Hall
Auburn, AL 36849
Dennis M. Donovan, Ph.D.
Professor of Psychiatry
and
Director
Alcohol and Drug Abuse Institute
University of Washington
Department of Psychology, Box 351415
Seattle, WA 98195-1415
Rudy E. Vuchinich, Ph.D.
Professor of Psychology
Auburn University
Department of Psychology
226 Thach Hall
Auburn, AL 36849
84
Tailoring Interventions to Clients:
Effects on Engagement and
Retention
Larry E. Beutler, Heidi Zetzer, and Elizabeth Yost
Drug abuse represents a major social and behavioral health problem.
National Institute of Drug Abuse (NIDA) statistics suggest that 37 percent
of the U.S. population has used illicit drugs (Smith 1992) and as many as
23 percent of the work force regularly do so in the workplace (Barabander
1993). Drug use in the workplace is not limited to benign, recreational
drugs. The NIDA estimates indicate that 3 percent of the work force
abuse heroin (Browne 1986) and over twice that figure abuse cocaine
(Abelson and Miller 1985). Chemical abuse affects family functioning,
work performance, and the health of newborn children (Levy and Rutter
1992). Of contemporary concern, opiate and cocaine abuse probably
represent the most significant problem because of their severe addictive
properties, the high likelihood of polydrug abuse among their users, and
the decline of social functioning that accompanies their abuse (Almog et
al. 1993). Three tasks face those who attempt to develop treatment
programs for drug abuse disorders: (1) developing procedures that
facilitate patient engagement in treatment, (2) developing procedures
that increase the likelihood of retention of individuals in treatment, and
(3) establishing the conditions under which even effective treatments
work best and least well. While this chapter will focus on the status of
research on the first two of these tasks, the last one cannot be ignored in
this process. This is true both because of the necessity of continually
testing the relationship between treatment engagement and dropout on
one hand and treatment efficacy on the other, and because there are
promising developments in the area of treatment efficacy that may
improve awareness of the significance of engagement and retention.
There is considerable contemporary interest in tailoring aspects of the
intervention to fit individual patient needs. Individualized treatments
offer the hope that sensitivity and specificity of interventions will
increase treatment retention and engagement rates as well as improve the
likelihood of clinical efficacy. Unfortunately, literature is sparse on the
application of tailored interventions to chemical abuse problems. Thus,
efforts to tailor handling of patients who suffer from these problems must
borrow and extract from research on other problems.
Two basic methods of matching treatments and patients have shown
enough promise in psychotherapy research to suggest that they may be
85
transportable to research on chemical abuse treatment. The first of these
methods focuses on matching personal qualities (e.g., personalities,
backgrounds, beliefs, and other characteristics) of patients and therapists
to increase the likelihood that they will develop a working relationship
that will enhance therapeutic progress. The second seeks to match
specific treatment procedures or strategies to particular characteristics
and needs of patients. A brief review of the status of these matching
procedures may help in the assessment of their applicability to substance
abuse treatment research.
PATIENT-THERAPIST MATCHING AND THERAPEUTIC OUTCOMES
One way to tailor interventions to clients of different types is to match
them to therapists who represent the most appropriate fit. Such patienttherapist matching has a long tradition in psychotherapy, covering the
gamut of matching variables from sociodemographic characteristics to
value and belief systems. Indices of treatment engagement have included
patient preferences and satisfaction levels. One line of research, for
example, has suggested that some ethnic minority clients prefer to work
with counselors who are of the same race, but this finding tends to vary
according to the client’s ethnicity and his or her level of ethnic identity
development and acculturation (Parham and Helms 1981; Sanchez and
Atkinson 1983). Summaries of this research usually conclude that while
African-American clients prefer African-American therapists over white
therapists (Atkinson 1983; Harrison 1975; Sattler 1977), a preference for
an ethnically similar therapist is not as evident among other ethnic
minority groups (Atkinson 1983). Atkinson (1983) observed that
inattention to within-group differences and constricted ranges of
acculturation might have prevented the emergence of preferences as a
distinguishing effect of ethnic matching among nonblack minority groups.
Sanchez and Atkinson (1983) remedied some of these problems by
including level of acculturation as an independent variable in their
investigation of racial similarity and therapist preference. They found
that Mexican-American college students with strong commitments to the
Chicano culture preferred racially similar counselors, while those who did
not have strong cultural identities did not. Interestingly, however,
Vietnamese refugees (presumably not acculturated) showed no preference
for a racially similar counselor (Atkinson et al. 1984). Somewhat
stronger evidence has accumulated to suggest that patient-therapist ethnic
similarity is associated with lower dropout rates during therapy (Krebs
1971; Terrell and Terrell 1984; Yamamoto et al. 1967).
86
Finally, therapist-patient socioeconomic status (SES) similarity has been
related to more positive perceptions of the therapist, but the relationship
between SES and either therapy process or outcome has not been investigated adequately.
Despite evidence that therapeutic engagement (e.g., therapist preference
and treatment retention) is enhanced by the assignment of a racially
similar therapist to minority patients, the extent to which this similarity
or dissimilarity affects engagement in the therapy process is far from
clear (Atkinson and Schein 1986). About half the studies examined by
Atkinson and Schein (1986) support the hypothesis that patient-therapist
ethnic similarity can enhance certain qualities of the therapy process,
including the working relationship, and at times even lead to improved
therapy outcomes. The other half of the research studies in those
authors’ review found no relationship among these factors.
It may be, however, that ethnic similarity is not the important variable in
studying the cultural fit of patients and therapists. Perhaps a broader
dimension of shared cultural values would provide a better test of the role
of ethnicity and background in psychotherapy change among certain
disenfranchised groups. In the most systematic effort to address this
latter issue, Smith and colleagues (1980) assigned an index of cultural
similarity to each of the 475 studies in their meta-analysis of
psychotherapy outcome, based upon the degree to which client and
therapist samples shared a common educational, economic, and upwardly
mobile history. An effect size of only 0.10 was obtained using this
variable, suggesting that little variance in outcomes could be attributed to
similarity of culturally derived attitudes.
There is also little evidence in contemporary literature to indicate that
gender similarity, age similarity, or physical ability similarity have an
effect on psychotherapeutic engagement, relationship enhancement, or
treatment outcome (Atkinson and Schein 1986), though patients,
regardless of their status on these dimensions, tend to prefer female
(Stricker and Shafran 1983), middle-aged (Simon 1977), and physically
disabled therapists (Brabham and Thoreson 1973; Mitchell and
Frederickson 1975).
Collectively, these findings suggest both that different ethnic groups
respond differently to demographically similar therapists and that sharing
certain attitudes, rather than simply demographic background, may be
more important in facilitating patient engagement and commitment.
This con-clusion may be seen as supportive to the position, often taken
in chemical abuse treatment programs, that therapists who share the
87
patient’s history of substance abuse may be better able to provide help
than therapists who do not have a history of chemical abuse. The results
of research on this topic have shown some support for this view, at least
for enhancing the therapeutic alliance (Argeriou and Manohar 1978;
Lawson 1982). For example, Lawson (1982) found that counselors who
were in alcohol recovery were judged by their alcoholic patients to show
higher regard and greater unconditionality than counselors without
alcohol problems. Results regarding attrition and outcome in these
treatment programs are not available. Nonetheless, this work raises the
importance of considering patient and therapist fit along dimensions of
personality and attitude.
Viewing literature on broad personality dimensions reveals evidence of
some relationship between the degree of patient-therapist similarity and
the strength of the therapeutic relationship (Atkinson and Schein 1986).
Though not replicated extensively in contemporary research, similar
personality styles, as measured by the Myers-Briggs Type Indicator, have
been associated with improved treatment retention rates (Mendelsohn and
Geller 1963, 1965). However, treatment duration does not necessarily
indicate treatment benefit. For example, Swenson (1967) found that
dissimilarities on the specific dimensions of dominance and submission
were directly related to treatment gains. Likewise, several reviews
conclude that dissimilar, rather than similar, personality traits are
associated with better outcomes and greater patient satisfaction levels
(Atkinson and Schein 1986; Beutler 1981).
Therapist conceptual level is another personality trait that has been the
focus of both theoretical and empirical work over several years. Unlike
findings related to dominant and submissive traits, however, this research
generally supports the value of patient-therapist similarity. Similarity in
conceptual level has been particularly related to retention in treatment
(Holloway and Wampold 1986; Lamb 1977; McLachlan 1972; Stein and
Stone 1978). For example, Hunt and colleagues (1985) explored the
effects of cognitive style match among consecutive admissions to the
University of Washington Psychiatric Outpatient Clinic. They found
that 60 percent of the premature terminations occurred in mismatched or
dissimilar dyads while only 24 percent occurred in dyads with similar
cognitive styles. Among clients who continued therapy, similar dyads
were associated with more symptomatic changes at the end of 12 weeks
of treatment than dissimilar dyads, an effect that disappeared quickly
when mismatched groups caught up to the similar group. These findings
suggest that similarity of cognitive style facilitates retention in therapy
and may even speed improvement in the early sessions of therapy.
88
As the contradictory findings from these studies on conceptual level and
dominance-submissiveness would suggest, it is difficult to generalize from
any one variable within the domains of personality and belief systems to
others, even within similar domains. No single conclusion is warranted
that applies to a broad range of beliefs or personality characteristics
regarding whether similarity or difference is more facilitative of
retention, engagement, or outcome in psychotherapy. However, a
relatively consistent theme does emerge to suggest that increasing
patient-therapist similarity on a wide variety of these variables over the
course of therapy is associated both with indicators of engagement and
improvement. For example, Foon (1985, 1986) reported that among a
diagnostically heterogeneous group of 78 adult outpatients and their 21
therapists, end-of-therapy similarity of locus of perceived control, but
not pretreatment similarity, was positively associated with improvement,
indicating that convergence of client-therapist perceptions is a factor in
achieving benefit. Patient-therapist convergence has been a particularly
consistent observation in research on patient belief and value systems, a
conclusion that partially reflects and has been supported by a relatively
large series of studies from the authors’ laboratory (Beutler et al. 1991a).
Six critical qualitative reviews of this research have all concluded that
clients tend to adopt the personal values of their therapists during the
course of successful psychotherapy, independently of the type of problem
presented (Atkinson and Schein 1986; Beutler 1981; Beutler and Bergan
1991; Beutler et al. 1991b; Kelly 1990; Tjelveit 1986). According to
these reviewers, patients who become converted to the therapist’s beliefs
or values have good outcomes. A review of the six most
methodologically sound studies on this topic (Kelly 1990) suggests that
value conversion may be related most closely to therapist ratings of
improvement, but the effect, nevertheless, does extend to the outcomes
assigned by external raters and the patients themselves.
A second generalizable, but somewhat weaker, conclusion also emerges
from this literature. Three of the six reviews (Beutler 1981; Kelly 1990;
Tjelveit 1986) inspected the relationship between initial therapist-client
similarity and subsequent improvement, noting that initial dissimilarity of
client and therapist values was associated with the subsequent adoption of
the therapists’ values and beliefs.
None of the six qualitative reviews reached a clear determination as to
whether initial global value similarity or dissimilarity is more conducive to
client improvement. Likewise, Foon (1985, 1986) found that initial
patient-therapist similarity on the dimension of perceived locus of
control was not predictive of treatment outcome. It appears that while
89
global value and personality convergence are associated with positive
outcomes, and while initial dissimilarity on these global dimensions is
associated with convergence, neither global value/belief similarity nor
dissimilarity are consistent predictors of treatment response (Beutler
1981; Tjelveit 1986).
Some effort has been devoted to looking at and comparing specific value
and personality characteristics within the patient-therapist dyad that will
identify a pattern of initial similarities and dissimilarities that will relate
to positive treatment outcomes. Such a pattern, if identified, could serve
as a template for assigning patients to therapists with whom they would
work well. Some relatively weak but promising conclusions seem to be
emerging from this literature. The findings indicate that psychotherapy
improvement may be enhanced by a complex pattern of similarity and
dissimilarity between client and therapist belief and value systems (e.g.,
Beutler et al. 1974; Cheloha 1986). In the authors’ laboratory, a series of
studies has suggested that treatment success is enhanced when clients and
therapists are similar in the relative value placed upon such qualities as
wisdom, honesty, intellectual pursuits, and knowledge (e.g., Arizmendi et
al. 1985; Beutler et al. 1974). At the same time, client-therapist
discrepancies in the value placed on personal safety (Beutler et al. 1978),
interpersonal values, social status and friendships (Arizmendi et al. 1985;
Beutler et al. 1974, 1983) have been found to facilitate improvement. At
least some of these findings have been supported by independent research
programs (Charone 1981; Cheloa 1986).
In sum, while demographic similarity and conceptual level appear to be
related to dropout, value conversion and a complex pattern of individual
belief and value similarities and dissimilarities appear to be related to
improvement. To date, however, none of these lines of research has
inspected retention and improvement rates within drug-abusing populations. Typically, patient samples have been diverse outpatient groups
with very heterogeneous problem types. The research to date is
promising, especially in its implications to retention rates. It provides a
fertile field in which treatment retention rates among chemical abuse
patients might be explored. Clearly, more research on the types of
similarity dimensions that are positively, nonsignificantly, and negatively
associated with different types of retention and improvement will be
necessary to apply these promising relationships to problems of chemical
abuse.
MATCHING PROCEDURES TO PATIENT NEEDS
90
Efforts to define various psychotherapy methods that are effective either
for those with a common diagnosis, such as drug abuse, or with a specific
symptom, such as depression, have largely concluded that all psychotherapy approaches produce similar mean effects (e.g., Beutler et al.
1986; Lambert et al. 1986; Smith et al. 1980). The studies that support
these conclusions are largely based on a randomized clinical trials
methodology that has been borrowed from psychopharmacological
research. The methodology of this research paradigm is to study a single,
diagnostically homogeneous sample of patients and to compare the
efficacies of one or more packaged, reliably applied, and brand-named
treatments. In this paradigm, nondiagnostic patient characteristics are
usually studied as a secondary, post hoc variable when, as is usually the
case, no significant differences are observed between two packaged
treatments.
Depression and its various subtypes have been the target of most studies
of psychotherapy. Fortunately, there are reasons to believe that there
are links between depression and substance abuse that will allow this body
of research to transfer to chemical-abusing populations. For example,
depres- sion is a frequent coexisting condition both in drug abuse and
during drug withdrawal (Weiss et al. 1992). Whether cause or
consequence, the coexistence of drug abuse and depressive symptoms
suggests that psycho- behavioral interventions that are effective in
treating depression also may be effective treatments for chemical abuse.
Because of the demands of randomized clinical trials research, a number of
well-established treatments of depression also have evolved, many of
which are potentially transportable to the area of chemical abuse. For
example, mounting evidence suggests that even in the case of endogenous
depression, the condition most often thought to be weighted toward the
role of biological precipitators, manualized forms of cognitive therapy are
effective in both relieving depression and preventing its recurrence
(Corbishley et al. 1990; Jarrett et al. 1990; Simons and Thase 1992).
Moreover, cognitive therapy, though initially formulated and manualized
as a treatment for depression (Beck et al. 1979), in recent years has
successfully been adapted as a treatment both for drug abuse (Wright et al.
1993) and alcoholism (Wakefield et al., in press).
Similarly, treatment manuals based upon relationship-oriented therapies
(both psychodynamic and interpersonal models) have been successfully
extrapolated from research on the treatment of depression and anxiety
disorders for application in the treatment of opiate abuse (McLellan et al.
1983; Rounsaville et al. 1987). The use of manuals within the context of
the usual clinical trials research model is well adapted to revealing which
91
systematic therapies are effective in treating specific diagnostic groups,
but is of limited value for assessing questions of matching treatments to
patients. Nonetheless, the translations of established manuals to
chemical- abusing populations have provided a foundation for
explorations of the conditions under which different psychotherapies and
psychotherapy procedures are maximally effective.
The effort to fit treatments—variously called "eclectic," "integrative,"
and "prescriptive" psychotherapies—to patients has evolved largely in
the last decade. Two approaches to matching patients to treatments have
been employed in these prescriptive models. One has been to develop
different manualized therapies for patients with different diagnostic
conditions. In this approach, an effort is made to construct a theoryconsistent therapy that can be applied in a somewhat different form to
several different and diagnostically distinct patient groups. The
foundation studies for this method usually concentrate on demonstrating
the clinical efficacy of each within the patient samples for which it was
designed rather than on comparing the efficacy of the different manuals.
A second approach to matching patients to treatments has been to define
characteristics of treatment procedure and strategy that distinguish
different theoretical approaches to psychotherapy, and then to identify
the patient characteristics on which these procedures are differentially
effective. The foundation studies for this approach to prescriptive
matching have been those in which two or more manualized therapies are
applied to two or more patient groups. Rather than being selected solely
on diagnostic grounds, the patient groups for this approach usually are
stratified on the basis of a variable that is thought on empirical or
theoretical grounds to be differentially responsive to the therapies studied.
Differentiating aspects of each treatment are related to differential
efficacy on the diverse samples of patients, yielding conclusions about
those treatment characteristics that best fit the patient characteristics. In
these studies, the patient characteristics of interest are often extradiagnostic in nature.
While the first approach works within a single theoretical system to
develop variations that fit different diagnostic groups, a major aim of the
latter approach is to develop guidelines for mixing and combining
procedures from across theoretical models to maximally tailor
interventions to specific patient characteristics that are not captured well
in diagnosis. Both types of studies provide leads to indicate the patient
and treatment dimensions that will make the most effective matches.
92
STATUS OF INTEGRATIVE TREATMENTS
To compare the relative value of the two prescriptive treatment methodologies described above, Beutler and Crago (1987) compared studies that
used a variety of methodologies to calculate the percentages of explained,
within-subject variance accounted for by each approach— different
treatment models applied to patients with different diagnoses versus
contrasting treatment models applied to nondiagnostic patient variables.
The value of the two approaches was assessed against a base rate
expectation of 10 percent, the amount of variance attributable to
different treatment types when patient variables are not considered. The
base rate figure of 10 percent was derived from a variety of research
reviews of comparisons of different psychotherapy models (Lambert
1989; Lambert and DeJulio 1978; Smith et al. 1980).
The comparisons indicated that the interaction effects attributable to
combinations of psychotherapy types by patient diagnoses increased the
amount of outcome variance accounted for from 10 to 15 percent, a very
modest increase over the base rate of 10 percent. This finding confirmed
the suggestion (Howard 1989) that even in manualized treatments of
diagnostically homogeneous patient groups, the variability of outcomes
among treatments is very broad. In any defined and uniformly applied
treatment, there appears to be a relatively large number of patients who
get better and a smaller but substantial number who do not. Apparently,
diagnostic variables are insufficient to reduce the wide variance in
outcomes that are secured by all treatments.
When Beutler and Crago considered studies that matched patients and
treatments in ways other than through patient diagnosis or brand-named
therapies, they had more success in establishing the presence of
differential effects among treatments. Matching treatments to select
nondiagnostic variables increased the amount of attributable variance to
an average of 30 percent, and some variables accounted for as much as 60
percent of the variance in patient responses.
Some patient variables that have been found to interact most successfully
with treatment procedures are coping styles (Beutler 1979; Beutler and
Mitchell 1981; Sloane et al. 1975), levels of resistance (Beutler et al.
1991c, 1991d; Shoham-Salomon and Hannah 1991), cognitive
organization (McLachlan 1972), and aspects of problem severity and
distress (Imber et al. 1990; Luborsky et al. 1985).
Promising Matching Dimensions
93
Drawing from studies representing each of the foregoing approaches, an
inspection of the most promising findings suggests that:
• Experiential therapies often are more effective than cognitive
and dynamic therapies either when used early in treatment or when
applied to those who are insufficiently distressed about their problems
to support emotional growth (Beutler and Mitchell 1981; Greenberg
and Safran 1987; Mohr et al. 1990; Orlinsky and Howard 1986);
• Nondirective and paradoxical interventions are more effective
than therapist-directed ones among patients with high levels of
pretherapy resistance (i.e., resistance potential or reactance) (Beutler
et al. 1991c, 1991d; Forsyth and Forsyth 1982; Shoham-Salomon and
Hannah 1991); and
• Therapies that target cognitive and behavior changes are more
effective among impulsive, externalizing patients than those that
attempt to facilitate insight. The latter effect has often proven to be
reversed among patients with internalizing coping styles (Beutler et
al. 1991c, 1991d; Calvert et al. 1988; Sloane et al. 1975).
All of these relationships have been found to be sufficiently robust to be
revealed in a variety of diagnostic disorders. Thus, they carry
implications for the prescription of psychotherapeutic strategies and
procedures that are extracted and combined across theoretical models (see
Beutler and Consoli 1992; Beutler and Hodgson 1993; Gaw and Beutler
1995). The robust effect of many of these parameters suggests that
combined treatments, based upon these relationships, may be applicable
to chemical abuse dependencies as well as to a variety of mental health
disorders.
On a more negative note, even the best among the available research
studies on this topic have oversimplified the complexity of matching
patients and treatments. With few exceptions, the long-term effects of
these variables on relapse and efficacy have not been investigated.
Neither has research, to date, investigated the interdependence and joint
effects of two or more patient and treatment dimensions operating at
once. The best studies include only one or two manualized variations of
therapy procedure as applied to a group of patients who are selected to
vary along a single dimension. No study to date has had the resources to
address the implications of assigning a treatment package composed of
several interventions to patients who vary on several indicators/
contraindicators at once.
94
The importance of considering multiple patient and treatment parameters
at once cannot be overstated. Even manualized treatments, if they are
not sensitive to the complexities of individual proclivities and the
treatments with which they fit (and this includes most contemporary
manuals), may unintentionally include treatment components for a given
patient that are offsetting when applied to a patient who embodies a
constellation of characteristics that do not fit. For example, the positive
effects of cognitive therapy applied to an externalizing patient may be
offset by the limited effective-ness of this same therapy with patients
who have high levels of resistance to therapist leadership or control.
Thus, comparisons of two or more treatments may fail to reveal
important differences within diagnostically homogeneous groups because
these groups include patients who have counterbalancing but unassessed
differences in indicating characteristics.
Extracting from research on the patient-treatment dimensions previously
identified, it is conceivable that treatment outcomes could be maximized
among substance abusers by fitting specific procedures from several
different treatment models to the unique combination of extradiagnostic
characteristics that is presented by the individual patients (e.g., combining
the symptom focus of cognitive therapy with the arousal-induction
procedures of relationship-oriented therapies for use with an
externalizing, nondistressed patient). This is an area where research is
needed.
Selecting the most promising combinations of procedures from among
those valued by the several hundred available theories (Corsini 1981)
requires that several patient and treatment dimensions be varied at once.
The complexity of patient and treatment variables (e.g., Lazarus 1981;
Orlinsky and Howard 1986; Parloff et al. 1978) makes it unlikely that
studies in which one brand of psychotherapy is pitted against another,
without regard for the patient characteristics that fit and fail to fit with
these treatments, will yield much information about treatment efficacy.
ILLUSTRATIVE RESEARCH
For descriptive purposes, findings that have been obtained and the
implications of some patient-therapy matching components will be
illustrated. For example, in a prospective test of the independent effects
of two matching dimensions among depressed outpatients, Beutler and
colleagues (1991c) selected manualized therapies that contrasted in
defined ways to provide greater and lesser fits to patients varying in
coping style and resistance potential.
95
Following 20 sessions of treatment, therapies that were directive and
therapist-guided were found to have opposite effects from a therapy that
was designed to be self-directed and nondirective when contrasting patient
groups were studied. Resistance-prone patients did poorly in the directive
therapies but well in the nondirective/self-directed therapy, while patients
who were not prone to high levels of resistance did comparatively better
with the directive therapies than the nondirective one. This finding was
independently crossvalidated on a sample of anxious and depressed
patients at the University of Bern utilizing a variety of alternative
measures of defensive anxiety (Beutler et al. 1991d).
Corollary work (Horvath 1989; Seltzer 1986; Shoham-Salomon et al.
1989; Shoham-Salomon and Rosenthal 1987) has confirmed the
conclusion that trait-like indicators of resistance may be a specific
indicator for the use of nondirective, paradoxical, and self-help
procedures. Shoham-Salomon and colleagues (1989) have demonstrated
that college students who were predicted to be highly resistant by voice
tone measures became worse when they were directly told to change
habits of procrastination. However, paradoxical assignments (i.e.,
"observe but don’t change your habits") resulted in a decrease in
symptoms. Confirmations in different populations (Shoham-Salomon
and Jancourt 1985) suggest that either low directive or paradoxical (don’t
change) instructions are indicated for patients judged to have high
propensities for resistance, while directive assignments are
contraindicated (Forsyth and Forsyth 1982).
Studying a second dimension, Beutler and colleagues (1991c) found that a
therapy that was designed to directly induce a change in symptoms of
depression worked more effectively among patients who had adopted
impulsive and other externalizing coping styles, but it was relatively
ineffective among those who were prone to internalize conflict and to be
excessively self-reflective. In contrast, therapies that were designed to
provoke self-awareness and insight worked best among internalizing
individuals but relatively less well among those who externalized their
conflicts and acted out.
Outcomes. Outcome analyses revealed that two of three outcome
measures were affected differently across treatments as a function of
patient coping style. The symptom-focused procedures of cognitive
therapy exerted their strongest effects among depressed patients who
exhibited externalizing coping styles. Less impulsive, depressed patients
did best with the insight-oriented procedures of a client-centered therapy.
This finding was subsequently independently crossvalidated on a sample of
96
depressed and anxious subjects at the University of Bern, utilizing a
variety of alternative measures of externalization (Beutler et al. 1991c).
Relapse. Another finding emerged from these studies that is important
to the development of matching dimensions. Beutler and colleagues
(1993) tabulated followup data from the completed study of depression.
They found that while relapse rates for depressed patients in all
treatments were very low (averaging 12 percent) over a 1-year period,
return of clinically significant depressive symptom levels was a function
of interactional matches between type of treatment and patient
characteristic. Externalizing patients in cognitive therapy had lower
relapse rates than either externalizing patients in the other treatment
conditions or than nonexternalizing patients in cognitive therapy. In
contrast, nonexternalizing patients in two insight-oriented psychotherapies had lower relapse rates than nonexternalizing patients in
cognitive therapy. Likewise, high-resistance patients in directive,
cognitive, and experiential therapies relapsed at a higher rate than
resistant patients in a nondirective therapy. Low-resistance patients in
directive therapies also relapsed at a relatively low rate.
APPLICATIONS TO SUBSTANCE ABUSE
With the exception of Project MATCH (alcohol abuse), randomized
clinical trials of psychotherapy for either depression or substance abuse
have not mirrored the integrative effort that characterizes clinical
practice. Kazdin (1983, 1986) has suggested that comparative studies of
packaged psychotherapies must be accompanied by dismantling and
combining strategies to refine the potency of interventions. The authors
believe that a variety of psychotherapies have now adequately
demonstrated their clinical efficacy and that more specific combined
strategies are now needed to define the dimensions of differential
treatment selection. However, without prospective, hypothesis-driven
research designs, the accumulation of empirical knowledge is likely to be
slow (Goldfried and Padawer 1982).
There have been several interesting studies of substance abuse that have
used aspects of treatment matching to look at ways of enhancing
treatment efficacy. Most notable among these, from the authors’
perspective, have been those of Kadden and colleagues. Kadden and
colleagues (1990) evaluated the relative effects of interactional
(insight/interpersonal therapy) and skills training (symptomatic/
behavioral) aftercare groups among 96 inpatient alcoholic patients who
were differentiated by their propensities toward sociopathic behaviors (an
externalizing quality). Interactional therapy proved to be most
97
efficacious among those with low sociopathic qualities—more
internalizing—while behavioral skills training was most efficacious among
those with high sociopathic qualities. After 2 years, results were obtained
that paralleled the findings of Beutler and colleagues (1991d) on patients
with major depression. Cooney and coworkers (1991) found that longterm relapse rates were also associated with matches of therapy and
patient types. Correctly matched groups produced less relapse and better
long-term gains than did poorly matched patients.
Though consistent with the research on depression, these latter findings
have not received universal support among substance abusers. For
example, Woody and colleagues (1985) found that sociopathy did not
differentiate between those patients in a methadone maintenance
program who responded to cognitive therapy and those who responded to
an insight-oriented therapy. In this study, however, the measure of sociopathy was categorical and diagnosis specific rather than being continuous
and symptomatic. Moreover, it was obtained by clinician ratings rather
than self-report. Thus, it is likely that the elements of coping style
reflected in this measure were different and more diagnosis specific than
measures used in studies of coping style.
Woody and colleagues (1983) did find some results that bear on the effort
to discover indicators and contraindicators for types of intervention.
They investigated the role of problem severity and level of impairment as
a con-tributor to differential outcomes of psychotherapies versus drug
counseling. They found that methadone-maintained, opiate-abusing
patients with severe problems did better in professionally run
psychotherapy programs. In contrast, those with less severe problems of
opiate abuse were able to benefit from less intensive drug counseling.
Alterman and colleagues (1991) have incorporated these findings and
others into a systematic set of suggestions for the differential treatment
of substance abusers.
The authors’ research group (Beutler et al. 1993) is currently
implementing a research program that was designed to demonstrate the
advantages of matching patient characteristics with psychotherapeutic
techniques. The program compares the differential effectiveness of
family systems couples therapy (Rohrbaugh et al. 1995) and cognitivebehavioral couples therapy (Wakefield et al., in press) in treating men or
women with a primary "Diagnostic and Statistical Manual of Mental
Disorders," 3d ed. revised (DSM-III-R) (American Psychiatric Association
1987) diagnosis of alcohol abuse or dependence. The participants are
engaged in 20 sessions of treatment with their partners over a period of 6
months. In addition to evaluating the efficacy of the two treatments in
98
reducing or eliminating alcohol intake, improving the quality of the
couple’s relationship, and alleviating psychological symptomatology, the
authors are also examining the differential effects of treatment for men
with two different drinking styles (episodic versus steady), two different
coping styles (internalizing versus externalizing), and varied levels of
interpersonal reactance. It is hoped that the importance of some of these
variables in both the selection of systems- versus symptom-focused
treatments and the application of other intervention strategies that
distinguish the treatments will be confirmed.
This study reflects the authors’ belief that the field is ripe for developing
methods of combining treatment procedures across theoretical models.
By combining aspects of different treatments into a single treatment
package based upon the patient indicators revealed in these studies, it may
be possible to improve treatment efficacy far over that obtained using
manualized, single-theory models. In support of this conclusion, several
recent theoretical and methodological articles have appeared in the
literature advocating a search for treatment by patient interaction
dimensions. A special series in the April 1991 "Journal of Consulting and
Clinical Psychology" was devoted to aptitude by treatment interaction
(ATI) in psychotherapy and posed some methodological suggestions as
well as advocating for an integrative, conceptual position. Likewise,
several textbooks of eclectic and integrative models of psychotherapy
have been published in recent years and are well received (Norcross 1986,
1987; Norcross and Goldfried 1992; Striker and Gold 1993). This level of
activity indicates that this is both an exciting and fruitful area of
investigation, and one with many potential applications, including
applications to drug and alcohol abuse.
Recommendations
In this chapter, treatment research studies on a variety of patient and
diagnostic conditions have been reviewed in an effort to find some
dimensions that may be extrapolated to the treatment of substance abuse
disorders. The focus of the review has been on efforts to match patients
either to specific therapists or to types of psychosocial treatments to
reduce dropout rates and increase treatment-related gains. It is impressive
that there is a growing body of research demonstrating meaningful, but
largely extradiagnostic, differences in the types of patients for whom
different treatment strategies and methods are effective.
Moreover, the advent of treatment manuals from randomized clinical
trials research, and the demonstration that some treatment strategies and
procedures from these manuals are more effective than others when
99
applied to distinguishable patient groups, have laid the foundation for
combining some of the procedures used in a variety of treatments in order
to tailor therapies to the needs of different chemical abusers.
Collectively, the review of literature suggests several promising directions
for future research.
1. Patient-therapist similarity on various aspects of background and
demographic variables appears to slow the rate and frequency of
premature termination. Some of these variables, most notably gender
and ethnic similarity, may also contribute to reductions in focal
symptoms. In the case of drug abuse, this literature suggests that
retention in treatment and declining use of drugs may be enhanced by
selecting and assigning therapists whose backgrounds are similar to
those of patients. The mechanism of this action is uncertain, but at
least conceptually it is associated with the patient’s ability to identify
with the therapist and to find the therapist to be a credible and
believable individual.
2. Aspects of patient and therapist dissimilarity may also be important,
especially for facilitating symptomatic change. For example, the
patient’s ability to accept and adopt the therapist’s general view of
life appears to be associated with improved functioning, especially as
rated by the therapist. Concomitantly, the presence of contrasting
attitudes and values between therapist and patient seems most
conducive to the emergence of this conversion process.
3. Certain patterns of initial patient-therapist similarity and dissimilarity
of viewpoint and personality also are conducive to facilitating
improvement, irrespective of the process of attitude convergence.
Similarity of cognitive conceptual level, social values, and intellectual
values, combined with dissimilarity of interpersonal needs for
closeness or ascendence, appear to be an optimal pattern.
4. Defining a fit between patient characteristics and therapy procedures
also appears to be possible. Among the best studied patient-therapy
dimensions are the effects of matching patient coping style to the
symptom or insight orientation of the therapy. Impulsive,
charactero-logical patients seem to do best in behavioral and
cognitive therapies, while overcontrolled, internalizing patients do
best with insight-oriented therapies.
5. Similarly, it appears that patients who have strong tendencies to resist
external control through oppositional behaviors do best when treated
100
with nondirective and paradoxical therapies. Conversely, patients
who exhibit more cooperative and less resistant reactions to external
demands are likely to benefit from therapies led and directed by the
therapist.
6. Therapies that combine a number of procedures from several different
models in order to accommodate both the patient’s coping style and
level of interpersonal resistance may be maximally effective. This
cross-theory eclecticism may entail a number of other dimensions, as
well, with the expectation that it may have increasing effects on
symptom reduction. Combining patient-therapist assignment and
patient-therapy treatment selection may create an opportunity to
both decrease dropout rates and to increase treatment efficacy.
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ACKNOWLEDGMENT
Work on this chapter was supported by grant no. AA 08970 from the
National Institute on Alcoholism and Alcohol Abuse awarded to Larry
Beutler (PI), Theodore Jacob, and Varda Shoham (co-PIs).
108
AUTHORS
Larry E. Beutler, Ph.D.
Professor of Education and Psychology
Heidi Zetzer, Ph.D.
Project Coordinator
Elizabeth Yost, Ph.D.
Visiting Associate Professor
Couples Alcoholism Treatment Project
Counseling/Clinical/School Psychology Program
Department of Education
University of California
Santa Barbara, CA 93106
109
Factors Associated With Treatment
Continuation: Implications for the
Treatment of Drug Dependence
Gregory G. Kolden, Kenneth I. Howard, Elizabeth A. Bankoff,
Michael S. Maling, and Zoran Martinovich
INTRODUCTION
It is well known and problematic that a significant number of people who
suffer from a diagnosable disorder do not seek out and receive the mental
health services they need (e.g., Vessey and Howard 1993). Even among
those who do seek treatment, many do not accept the recommended
regimen. For example, the majority of people who initiate psychotherapy
terminate relatively early in the process (Craig and Huffine 1976; Garfield
1994; Sue et al. 1976). In Garfield’s (1994) review, the median duration of
treatment was between five and eight sessions in studies where patients had
received at least one session of psychotherapy.
For some time, premature termination has been considered a major problem
(Straker 1968), one that occurs with all forms of treatment. Considerable
time and resources are spent in the attempt to engage patients in the
psychotherapeutic venture (Garfield 1986; Howard et al. 1986) and potential
benefits are not realized (Schafer 1973).
Researchers have responded to this ubiquitous problem by examining such
patient factors as demographic characteristics, pretherapy training,
psychological test scores, and expectancies concerning therapy in efforts to
find correlates of continuation in treatment (see Garfield 1994 for a review).
Time parameters for therapy have also been examined. For example, in one
study, time-limited therapy was found to be associated with fewer dropouts
than either time-unlimited or brief treatment models (Sledge et al. 1990).
From numerous efforts to date, only small percen-tages of variance have
been accounted for in premature termination or continuation in
psychotherapy.
In summarizing the literature on patient characteristics, Garfield (1994) has
concluded that variables pertaining to social class (low social class was related
to premature termination) were most consistently, but not invariably,
implicated by empirical evidence. Education showed some relationship to
therapy duration, while age, sex, and diagnosis seem to have no relationship
110
to treatment compliance. Pretherapy training for patients was
inconsistently associated with premature termination. Psychological test
variables were also not successfully predictive of continuation; however,
three studies have documented that compliance with a research protocol
(e.g., completion of pretherapy questionnaires) predicted continuation.
Finally, the degree of congruence between patient’s and therapist’s
expectations about therapy duration has shown some evidence of playing a
role in patient retention, but this evidence is not substantial.
Investigators and clinicians alike have been interested in ascertaining which
patient, therapist, or dyadic interaction variables influence contin-uation in
psychotherapy. Many studies have attempted to address this issue and the
findings (summarized above) have been documented in several reviews (e.g.,
Baekeland and Lundwall 1975; Garfield 1994; Reder and Tyson 1980;
Wierzbicki and Pekarik 1993). Few consistently replicable results have
emerged that point to any specific characteristic that would facilitate
differentiation between those who stay in psycho-therapy and dropouts to
any significant degree. Wierzbicki and Pekarik (1993, p. 194) offered the
following summary of this situation: "...[T]he types of simple variables
typically investigated in dropout research are not strongly associated with
dropout; hence, future research should use more complex psychological
variables." This clearly highlights the importance of the systematic
identification and subsequent examination of complex psychosocial input
and process variables via methods that extend beyond the analysis of single,
simple patient characteristics as they relate to therapy engagement and
retention.
A MODEL OF RELEVANT PSYCHOSOCIAL VARIABLES
Based on extensive literature reviews (Howard and Orlinsky 1972; Orlinsky
and Howard 1978, 1986a), a conceptual framework was developed that
describes patient characteristics that might influence use of individual
psychotherapy. This model posits four categories of psychosocial variables:
• psychopathology (presenting symptoms or syndromes) refers to
manifest psychiatric symptomatology; it is concerned with the types and
intensity of distressing experiences and behaviors as well as functional
impairment;
• pathology proneness (psychological vulnerabilities or predispositions) entails the concept of psychological vulnerability or
predisposition to the development of psychopathology; it may stem
from biological, personal, or situational factors. People who are
111
pathology prone have relatively pervasive handicaps or deficits that
make it difficult for them to cope with the challenges and stresses of a
wide variety of life situations;
• environmental stress involves the presence and frequency of
negative or problematic life experiences; and
• feasibility and attitudes toward treatment (patient motivation,
psychological resources, and related characteristics) refers to practical
barriers (e.g., schedule, fees), psychological resources (e.g., ability to
delay gratification), and attitudes (e.g., confidence that treatment will
help) that characterize a patient’s approach to the therapy enterprise.
Psychopathology tends to arise in people as a function of the influence of
environmental stress on pathology proneness. Pathology proneness is a
proximal contributor to psychopathology, while environmental stress is a
more distal contributor. It is important, therefore, to consider these factors
when examining patient characteristics predictive of psychotherapy continuation. Feasibility and attitudes toward treatment are also important as
they are relatively proximal contributors to treatment utilization.
THERAPEUTIC PROCESS: THE GENERIC MODEL OF PSYCHOTHERAPY
Theory and research involving psychotherapy process has suffered generally
from the lack of more universal conceptualizations of therapy to guide the
formulation of ideas and studies. This is certainly one factor contributing to
the meager amount of empirical research that examines process in relation
to continuation in psychotherapy. The generic model of psychotherapy
(Orlinsky et al. 1994; Orlinsky and Howard 1986a, 1987) provides a
transtheoretical conceptual framework that describes the relationships
among contexts, processes, and outcomes common to all treatments.
Five therapeutic processes are identified in the generic model— therapeutic
contract (e.g., keeping appointments, paying fees, cooperative
participation), therapeutic operations (intervention techniques and procedures), therapeutic bond (empathy, affirmation, collaborative alliance),
therapeutic openness (psychological availability and lack of defensive-ness),
and therapeutic realizations (e.g., in-session impacts such as unburdening,
encouragement, and insight). Subsequent empirical work has highlighted the
importance of these processes as well as having documented the model’s
validity (Ambühl 1991, 1993; Ambühl and Grawe 1988; Grawe 1989; Kolden
1991, 1993; Kolden and Howard 1992; Saunders et al. 1989).
Psychotherapy process variables constitute another important category of
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variables to examine in the pursuit of characteristics predictive of
psychotherapy continuation.
ENGAGEMENT, RETENTION, AND DOSAGE
Most research related to continuation in psychosocial interventions has
focused on dropout or attrition. The current analyses focused on the process
of engagement and retention in psychotherapy. Patient engage-ment in
treatment was defined as a sum of the patient’s responses to six multiple
choice questions, some filled out by patients before treatment, others after
the first session. Thus, this concept captures the personal perceptions of
patients who attended at least one session of psycho-therapy. (See appendix
A for a list of these questions.) Retention in psychotherapy was
operationally defined as remaining in treatment for at least three sessions.
A third focus of this study involved the examination of process variables in
relation to continuation in therapy. Continuation was conceptualized
according to the likelihood of having been exposed to a dose of therapy
(dosage is a construct involving a unit of analysis operationalized according
to the probability of bringing about an impact from a particular intervention
(e.g., pesticide, drug, session of psychotherapy)). Howard and associates
(1986) estimated that six to eight sessions were required for a psychotherapy
patient to have a 50 percent chance of improving. Thus, dosage was
conceptualized dichotomously as remaining in treatment for one to five
sessions versus six or more sessions; a patient continuing in therapy for six
or more sessions has a reasonable probability of having been exposed to a
dose sufficient to bring about clinical improvement.
METHODS AND PROCEDURES
A large, systematic, naturalistic study of psychotherapy utilization provided
the database for this study.
Patients
Psychotherapy outpatients (N = 450) who sought individual psycho-therapy
at Northwestern University’s Institute of Psychiatry participated in this
study. Participation was voluntary, informed consent was obtained, and
confidentiality of responses was ensured.
The number of sessions attended by individual patients ranged from zero to
more than 300; the median number of sessions was about 15. The typical
113
patient was single, white, female, between the ages of 22 and 35, and had
completed at least some college. In general, patients were self-referred for a
variety of mild to moderate disorders. In terms of demographic
characteristics, this patient sample is reasonably representative of the
psychotherapy outpatient population (cf., Taube et al. 1984; Vessey and
Howard 1993).
Therapists
Seventy-seven therapists participated in collecting data on which the current
analyses were based. The majority were in some stage of training—
psychology practicum students, psychology interns, psychiatry residents—
although most had had considerable additional experience. Forty-seven
percent of the therapists were psychiatrists, 28 percent were social workers,
and 25 percent were psychologists. Eighty-six percent were between 20 and
39 years of age, 51 percent were female, and 45 percent were married.
The dominant theoretical orientation of these therapists was
psychodynamic; supervisors typically espoused this approach, case
presentations followed this model, and case conceptualizations were usually
made from this perspective. Thus, the type of psychotherapy represented in
this study can be generally described as dynamic. No treatment manuals were
followed explicitly.
Instruments
Independent variables included sociodemographic characteristics and a
battery of patient-reported and therapist-reported scales measuring various
aspects of psychopathology, pathology proneness, environmental stress, and
feasibility and attitudes toward treatment. Patient and therapist ratings of
psychotherapy process variables were also examined.
Psychopathology. The extent of psychopathology was measured using
patient self-report measures including the Symptom Checklist (40-item
version adapted from Derogatis 1977; internal consistency = 0.94), Current
Life Functioning (23-item measure; Howard et al. 1992; internal consistency
= 0.93), Subjective Well-Being (4-item measure; Howard et al. 1992; internal
consistency = 0.79), and a brief version of the Inventory of Interpersonal
Problems (IIP; 27-item version adapted from Horowitz et al. 1988; internal
consistency = 0.88). The IIP has six subscales: hard to be assertive (internal
consistency = 0.80), hard to be sociable (internal consistency = 0.70), hard
to be submissive (internal consistency = 0.47), hard to be intimate (internal
consistency = 0.63), too responsible (inter- nal consistency = 0.62), and too
controlling (internal consistency = 0.68).
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Therapist-reported measures included the Global Assessment Scale (Endicott
et al. 1976; test-retest = 0.68 in current sample; test-retest ranges from 0.66
to 0.92 according to Dworkin et al. 1990), Level of Functioning (Carter and
Newman 1980; test-retest = 0.60), and the Life Functioning Scales (Howard
et. al. 1992; internal consistency = 0.86). The Life Functioning Scales
consist of six subscales: family functioning (test-retest = 0.60), health and
grooming (test-retest = 0.70), intimate relationships (test-retest = 0.64),
self-management (test-retest = 0.58), social relationships (test-retest =
0.68), and work, school, household functioning (test-retest = 0.70).
Pathology Proneness. Patient-reported measures of pathology prone- ness
included a brief version the Dysfunctional Attitudes Scale (10-item version
adapted from Weissman 1979; internal consistency = 0.81), Interpersonal
Attitudes Scale (10-item measure; Bankoff and Howard 1988; internal
consistency = 0.70), Self-Esteem (Rosenberg 1979; inter- nal consistency =
0.89), and the Coping Strategies Inventory (CPI; 40-item measure of coping
resources developed by Tobin et al. 1989; internal consistency = 0.91). The
CPI has four subscales: emotion-focused disengagement (internal consistency
= 0.86), emotion-focused engage-ment (internal consistency = 0.90),
problem-focused disengagement (internal consistency = 0.79), and problemfocused engagement (internal consistency = 0.85).
Therapist-reported measures included scales from the Personality Assessment Form (PAF; Pilkonis and Frank 1988). Perry and associates (1991)
developed and psychometrically evaluated three subscales based on a factor
analysis of the PAF: aggressive (internal consistency = 0.77), anxious
(internal consistency = 0.73), and eccentric (internal consistency = 0.62).
Environmental Stress. Patient-reported measures related to life stress
included an adaptation of the Life Stress Inventory (61-item measure
developed by Holmes and Rahe 1967) and Bankoff’s Social Support Scales
(Bankoff 1985). The Social Support Scales contain six subscales: nurturance
support (internal consistency = 0.85), patient role support (internal
consistency = 0.82), strength of network ties (internal consistency = 0.82),
pressure (from others) to seek treatment (internal consistency = 0.57),
density of friendship network (internal consistency = 0.27), and density of
overall network (internal consistency = 0.79).
The "Diagnostic and Statistical Manual of Mental Disorders," 3d ed. revised
Axis IV rating, Severity of Psychosocial Stressors (American Psychiatric
Association 1987), provided a therapist rating of life stress.
115
Feasibility and Attitudes Toward Treatment. Patient-reported measures of
feasibility and attitudes toward treatment included several selected items and
ratings from Saunder’s Process of Seeking Therapy Questionnaire (Saunders
1988).
Therapist-reported measures included five scales from the Therapeutic
Assets Questionnaire (Daskovsky 1988): Delay of gratification (internal
consistency = 0.76), willingness to enter treatment (internal consistency =
0.77), degree of distress (internal consistency = 0.61), psychological
mindedness (internal consistency = 0.86), and level of object relations
(internal consistency = 0.81).
Psychotherapy Process. The patient version of the Therapy Session
Report (TSR) (see Orlinsky and Howard 1986b for a review of the
development and utilization of this instrument) provided the measures for
three of the process variables used in this study—therapeutic bond,
therapeutic openness, and therapeutic realizations. The TSR is a 145-item
structured-response instrument that assesses experiences patients have during
a session of individual psychotherapy. It is typically administered following
a session and usually requires 10 to 15 minutes to complete. This study
utilized TSRs obtained from patients after the first session of psychotherapy.
The generic model of psychotherapy provided the guiding theoretical
framework for the development of the process scales. Internal consis-tency
for these scales has been established: 0.62 for therapeutic bond (Saunders et
al. 1989), 0.69 for therapeutic openness, and 0.86 for therapeutic
realizations (Kolden 1991). In addition, acceptable test-retest reliability has
also been demonstrated: 0.81 for therapeutic bond, 0.58 for therapeutic
openness, and 0.71 for therapeutic realizations. All scales have been shown
to have predictive validity in relationship to termination outcome (Kolden
1988; 1991; Kolden and Howard 1992; Saunders et al. 1989), early change in
mental health status (Kolden 1993), and treatment duration (Kolden and
Howard 1987).
The Therapeutic Procedures Inventory-Revised (TPI-R) (Orlinsky et al.
1987) is a therapist-rated questionnaire that assesses interventions used in
therapy sessions. McNeilly and Howard (1991) examined the internal
structure and psychometric properties of the section of the TPI-R addressing therapeutic operations. Factor analysis suggested three scales:
directive/behavioral, psychodynamic/past-focused, and experiential.
McNeilly and Howard (1991) reported the internal consistency for these
scales: 0.82 for prescriptive, 0.74 for exploratory/past-focused, and 0.63 for
exploratory/experiential. They also provided evidence for the external and
discriminative validity of these scales.
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The TPI-R also contains items addressing aspects of the therapeutic contract
(e.g., keeping appointments, paying fees, cooperative partici-pation). The
measure of therapeutic contract used in this study assesses this construct over
a 1-month period. Internal consistency for this variable has been
demonstrated to be only 0.26, a matter to be carefully considered when
interpreting findings involving this variable.
Dependent variables included three ways of conceptualizing psycho-therapy
continuation—engagement, retention, and dosage. Retention and dosage
were derived from therapy-episode duration, as described previously.
Engagement. The engagement scale was conceptually derived and composed
of six items. All responses were Likert scaled, with choices ranging from 1
to 5 for all items (except for one item, which had a 4-point range). Based
on a sample of 287 patients, Cronbach's alpha for the overall scale was 0.70.
Principal components factor analysis showed that 41 percent of item
variance was accounted for by a single factor, with loadings ranging from
0.46 to 0.71.
ANALYSES AND RESULTS
Tables 1 to 6 list the percent of variance in engagement and retention
explained by individual as well as by each set of patient-rated and therapistrated psychosocial variables. The indices of retention and engagement
appeared to be orthogonal (r = 0.07). Since about 50 con-trasts were
examined for engagement and retention, respectively, the criterion for
statistical significance was set at the 0.001 level. Only two variables met
this significance criterion with respect to engagement, while four met this
criterion with respect to retention. Moreover, the observed effect sizes for
nonsignificant results tended to be small (0 percent to 4 percent of variance
explained).
With respect to engagement, patients reporting positive feelings about
therapy tended to score higher on the engagement scale, t(186) = 4.93, p <
0.001. In addition, patients reporting relatively high confidence in a
successful outcome were more likely to experience higher levels of
engagement, t(187) = 3.53, p < 0.001.
Multiple regressions were computed for each of the sets of variables
shown in tables 1 to 6. For each set, the regression equation was used
to calculate a predicted engagement score for each patient. Then the
six estimated scores were entered into a multiple regression. The full
set accounted for 33.4 percent of the variance in engagement (p <
0.0001).
117
TABLE 1. Percent of variance in retention and engagement
accounted for by demographic variables.
Education
Employment
Marital status
Living alone
Age
Gender
R2
Retention (%)
0.9
1.2
0.6
0.1
0.0
0.1
2.7%
118
Engagement (%)
0.0
1.4
0.3
0.4
0.1
0.0
2.0%
TABLE 2. Percent of variance in retention and engagement
accounted for by psychopathology.
Patient-reported measures
Symptom checklist
Current life functioning
Subjective well-being
Interpersonal symptoms
Hard to be assertive
Hard to be sociable
Hard to be submissive
Hard to be intimate
Too responsible
Too controlling
Therapist-reported measures
Level of functioning
Global assessment scale
Life functioning scale
Family functioning
Health and grooming
Intimate relationships
Self-management
Social relationships
Work, school, household
R2
Retentio
n
Engagemen
t
0.1
0.2
0.1
0.4
0.1
1.2
0.1
0.1
0.5
0.1
0.2
0.0
0.6
1.5
2.0
0.0
0.0
3.9
2.5
0.0
0.0
0.4
1.0
0.3
0.1
0.0
0.6
0.8
2.6
1.2%
0.2
0.1
0.0
0.4
0.0
1.4
3.1
0.6
0.1
4.0%
With respect to treatment retention, patients who continued
for three or more sessions of therapy tended to receive higher
therapist ratings on delay of gratification (t(354) = 3.90, p <
0.001) and willingness to enter treatment (t(360) = 3.31, p <
0.001). They received lower ratings on
119
TABLE 3. Percent of variance in retention and engagement accounted
for by pathology proneness.
Patient-reported measures
Dysfunctional attitudes scale
Interpersonal attitudes scale
Self-esteem
Coping strategies inventory
Emotion-focused disengagement
Emotion-focused engagement
Problem-focused disengagement
Problem-focused engagement
Therapist-reported measures
Personality assessment form
Aggressive
Anxious
Eccentric
R2
Retention
Engagemen
t
0.3
0.8
0.0
2.0
0.2
1.4
0.0
0.1
0.8
3.1
0.5
3.2
0.1
0.4
0.0
3.3
0.2
0.0
6.6%
0.2
4.0
0.0
0.8
11.9%
TABLE 4. Percent of variance in retention and engagement
accounted for by environmental stress.
Retention
Engagement
Patient-reported measures
Life stress inventory
0.5
1.8
Social support scale
Nurturance support
0.0
1.3
Patient role support
0.5
1.0
Strength of network ties
0.1
2.7
Pressure to seek treatment
0.8
2.1
Density of friendship network
0.0
0.0
Density of overall network
0.8
0.5
Therapist-reported measures
Severity of psychosocial stressors
1.0
0.0
2
R
5.1%
10.6%
aggressiveness (t(335) = -3.38, p < 0.001) and work, school,
household functioning (t(334) = -3.34, p < 0.001).
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Again, multiple regressions were computed for each of the sets of
variables shown in tables 1 to 6. For each set, the multiple-regression
equation was used to calculate a predicted retention score for each
patient. Then the six estimated scores were entered into a multiple
regression. The full set accounted for 18.7 percent of the variance in
retention (p < 0.0001).
TABLE 5. Percent of variance in retention and engagement
accounted for by feasibility and attitudes toward treatment.
Patient-report measues
Effort required to
begin therapy
Prior psychotherapy
Confidence in
successful outcome
Expected treatment
duration
Feelings about
eginning therapy
Positive
Negative
Therapist-reported measures
Therpy assets
questionnaire
Delay of
gratification
Willingness to
enter treatment
Degree of distress
Psychological
mindedness
Level of objet
relations
R2
121
Retention
Engagement
1.1
0.1
0.0
0.0
0.1
11.6
0.8
0.9
0.4
0.1 6.3
4.0
4.1
0.6
3.0
0.0
0.4
0.2
0.1
0.1
0.8
0.1
9.6%
21.4%
TABLE 6. Percent of variance in retention and engagement
accounted for by the process of seeking therapy.
Duration of presenting problem?
Have you talked to anyone about it?
# of other attempts to solve
problem?
(1) Realizing the problem existed
Time until (1)?
Others help you
identify (1)?
Difficulty
acknowledging (1)?
(2) Thinking that therapy might
help
Time between (1)
and (2)?
Others help you
decide (2)?
Difficulty
acknowledging (2)?
(3) Deciding to seek psychotherapy
Time between (2)
and (3)?
Others help you
decide (3)?
Difficulty with
(3)?
(4) Calling for an appointment
Time between (3)
and (4)?
Self- versus otherreferred?
Difficulty with
(4)?
R2
Retention
0.0
0.5
0.2
Engagement
0.0
1.0
0.2
0.1
0.0
0.3
0.0
0.4
0.0
0.1
0.3
0.0
0.0
0.0
2.2
0.1
0.1
0.8
0.0
0.7
3.4
0.0
0.1
0.4
0.1
0.7
3.0
3.5%
9.9%
Table 7 summarizes the findings of correlational analyses examining
the relationship of psychotherapy process to dosage. These results
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TABLE 7. Percent of variance in dosage criterion accounted for by
first-session process variables.
Dosage criterion
Patient-reported measures
Therapeutic contract
Therapeutic bond
Therapeutic openness
Therapeutic realizations
Therapist-reported measures
Therapeutic interventions
Prescriptive
Past-focused
Experiential
R2
0.8
0.8
0.0
0.8
1.7
4.8
4.8
13.1%
demonstrated that the likelihood of remaining in therapy six sessions
or more was not associated with session one psychotherapy processes
to any consequential degree. Frequency of therapist intervention
activity in session one appears to be the only significant association
with dosage. Frequency of session one exploratory/past-focused and
exploratory/expe-riential operations were positively associated with
dosage. The full set of process variables accounted for 13.1 percent
of the variance in dosage (p = 0.07).
DISCUSSION
As in previous work, identifying predictors of treatment compliance
has once again proved elusive. A wide range of clinically relevant
variables was examined in this study, with a mere few emerging as
statistically significant as well as clinically interesting.
It was comforting, but not too surprising, to discover that optimistic
feelings about beginning therapy and confidence that therapy would be
helpful were positively associated with the process of engagement and
participation in the treatment enterprise. Similarly, the capacity to
delay gratification, an absence of aggressive personality
characteristics, better occupational/vocational functioning, and
willingness to be in therapy emerged as correlates of therapy
participation beyond two sessions (i.e., retention).
123
It was hypothesized that the nature of the psychotherapy process
would be positively associated with continuation in treatment:
reaching the dosage exposure criterion of six sessions. Frequency of
session one therapist intervention activity was the only substantial
finding to emerge.
The use of exploratory/past-focused and exploratory/experiential
techniques was each positively associated with reaching the dosage criterion for continuation. Patients experiencing higher frequencies of
these interventions may stay in therapy because of the early active
establishment of an exploratory intervention focus. Closer
examination of reasons for early therapy discontinuation might
further clarify this finding.
These conclusions must be considered in light of limitations inherent
in the current work. This was a naturalistic study of dynamic
psychotherapy delivered in a training clinic to a relatively diverse
group of psychiatric outpatients. The therapy was not manualized.
While naturalistic designs maximize generalizability and external
validity, limits to generalizability were introduced in this work by the
use of a nonmanualized, dynamic therapy in a training clinic.
Furthermore, the extent to which these findings generalize to
outpatient psychosocial drug treatment is a crucial question in the
context of the other chapters in this volume.
Predicting whether a patient will continue in an offered treatment
regimen, be it for depression or drug addiction, may be something like
predicting the final stopping place of a rock that begins rolling down a
mountainside. A huge number (finite in the sense that the number of
grains of sand on a beach are finite) of factors influence continuation
in treatment. The number of factors is not infinite in principle, but is
certainly too large for practical analysis. One solution that appears
workable is to take an individualized (i.e., idiographic) casemanagement approach in which the focus is on doing what is
necessary to increase the probability of keeping a particular individual
in the treatment enterprise. This may require more active
interventive efforts and expansion of traditional psychotherapist role
behaviors. These efforts might include pretherapy
psychoeducational sessions in which steps toward recovery are
outlined and patients are taught about their role in treatment, more
extensive use of phone contacts between sessions or when sessions are
missed, and explicit discussions of the importance of mutual
agreement with regard to therapy goals and interventions as well as
124
collaboration in the therapy relationship. Home visits, assuming an
advocacy role with employers, and family psychoeducation and
involvement might be other adjunctive modifications promoting a
comprehensive approach to treat-ment. All of these suggestions
speak to offering anything to ensure that a specific individual has the
opportunity to benefit from the treatment for the condition from
which he or she is suffering.
ACKNOWLEDGMENT
This work was partially supported by grants RO1 MH42901 and KO5
MH00924 from the National Institute of Mental Health. The
authors are grateful for the statistical work of Bruce Briscoe and Jerry
Halverson.
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AUTHORS
Gregory G. Kolden, Ph.D.
Assistant Professor of Psychiatry
Department of Psychiatry
University of Wisconsin
600 Highland Avenue
Madison, WI 53792
Kenneth I. Howard, Ph.D.
Professor of Psychology
Elizabeth A. Bankoff, Ph.D.
Research Associate
Michael S. Maling, Ph.D.
Research Associate
Zoran Martinovich, M.S.
Graduate Research Assistant
Department of Psychology
Northwestern University
Evanston, IL 60208
129
APPENDIX A
Patient Self-Report Items Comprising the Engagement Scale
1.
How important is it for you to be in psychotherapy at the
present time?
2.
How much have you thought about therapy since your last
session?
3.
During your last session, how much did you talk about
what you were feeling?
4.
To what extent are you looking forward to your next
session?
5.
At the present time, taking everything into consideration,
how close do you feel to your therapist?
6.
To what extent is your therapist someone you can talk to
about your private feelings and concerns?
130
Stages of Change: Interactions With
Treatment Compliance and
Involvement
Carlo C. DiClemente and Carl W. Scott
INTRODUCTION
Some powerful and effective treatment strategies currently are available
to assist substance abusers in modifying and stopping their problematic
behavior (Anglin and Hser 1992; Carroll and Rounsaville 1990; Miller
1993). As treatment technologies become more sophisticated and effective, the challenge becomes one of exposing clients to and engaging them
in their treatments. The problem is illustrated in what can be called the
smoking-cessation funnel effect. Often it is easier to get a picture of a
total population of individuals who are nicotine dependent than of those
who are using illegal drugs. In this illustration of a worksite (figure 1)
where 30 percent of the employees are smokers, it quickly becomes
apparent that many smokers express some interest in quitting in a general
survey. However, when an opportunity for treatment arises, few will
volunteer for treatment and sign up. The best estimates with extensive
recruiting are that only 4 to 10 percent will sign up, and that only 80 to
90 percent of these show up for treatment (Beiner and Abrams 1991).
Attrition, at its very least, would claim another 10 to 20 percent of
participating smokers. Finally, once the treatment is completed and subjects are followed up at 6 and 12 months, approximately 60 to 70 percent
of the treatment successes will relapse. Even with very liberal and hopeful estimates at each point in the process, the picture of recruitment,
retention, participation, and successful change for any one treatment
offering will be modest. Noncompliance and lack of long-term success are
two of the critical issues in substance abuse treatment that need to be
addressed.
A number of strategies have been proposed to increase engagement and
participation in treatment, including incentives and rewards, providing
information about treatment, easing treatment regimens, enlisting social
support of spouses and/or family members, self-selection of treatment
goals, court-mandated treatment, offering treatment in such restricted
settings as prisons, and treatment matching based on client, intervention,
131
or therapist characteristics (Becker and Maiman 1980; Beutler 1991;
Higgins and Budney 1993; Miller 1993; Project MATCH 1993; Smith
and Secrest 1991; Snow 1991; Sobell et al. 1992). It is certainly
neces-sary to know whether these strategies work. However, the
determination of how well they work is complex and depends on an
understanding of how and with whom each strategy might be
successful. In this chapter, the authors offer some ideas on the
critical dimensions not only for under- standing retention,
engagement, and change, but also for evaluating the effectiveness of
strategies purporting to modify or improve rates of recruitment,
retention, and participation.
Although there has been a great deal of discussion of the critical
dimen- sions related to retention and compliance, most of it has
focused on variables related to patient characteristics, disease or
disorder variables, or treatment or therapeutic relationship variables
(Baekeland and Lundwall 1975; Stark 1992). It seems timely to offer
some reflections about a dimension that often gets too little
attention: the process of behavior change that occurs both within and
without treatment. The goal of this chapter is to explain how this
process interacts with treatment(s) as well as how it can offer new
132
insights and a valuable additional perspective to the discussion of
retention and participation in treatments. A conceptual perspective
will be followed by some research evidence and then by an outline of
key implications or recommendations based on this process-of-change
perspective.
IMPORTANT DISTINCTIONS FOR UNDERSTANDING COMPLIANCE
AND CHANGE
Treatment and the Process of Change
Following a more medical view of substance abuse problems,
treatment providers have often assumed that treatment is absolutely
necessary for change. It is thought that without treatment,
individuals who are depen-dent on alcohol or drugs are condemned to
live their lives enslaved by the particular substance of abuse. Change
without treatment, in this view, can possibly happen in individuals
who abuse substances but not among those who are dependent on a
particular substance. In fact, stopping sub-stance use without
treatment is most often seen as confirming evidence that the
individual was not dependent on a substance. This is a rather circular
form of reasoning. The argument is: If a substance abuser can stop
using the substance on his or her own, then there must not have been
a significant problem because treatment is necessary for successful
sobriety or a drug-free existence for dependent substance abusers.
This reasoning has become so pervasive that it now permeates the
definition of dependence in the "Diagnostic and Statistical Manual of
Mental Disorders," 3d ed. revised (DSM-III-R) (American Psychiatric
Association (APA) 1987). One criterion for dependence is a
"persistent desire or one or more unsuccessful efforts to cut down or
control substance use" (APA 1987, p. 168). Problem definition,
treatment need, and the process of change have become confused and
confounded. This is not to say that treatment is not important for
change, but to indicate that treatment and change are not
coextensive.
It is important and necessary to disentangle these constructs in order
to develop a solid understanding of treatment retention and
participation. The following statements represent the proposed
theses that are the foundation of this chapter and that can alleviate
the confusion.
133
1. Substance abuse and dependence represent problems that are very
difficult to modify. However, there is ample evidence that some
individuals can change these behaviors on their own without
treatment (DiClemente and Prochaska 1985; Klingemann 1991;
Sobell et al. 1993; Tuchfeld 1981). Changes that occur in control
groups in clinical trials also support the contention that change
occurs with minimal amounts of what are considered the active
ingredients of treatment (Lambert et al. 1986).
2. Treatment represents a single and rather specific means of
changing substance abuse problems. Most individuals are not
successful with a single treatment and often undergo several
different—at times, radically different—treatments before they
are able to modify their behavior (Brownell et al. 1986; Marlatt
and Gordon 1985; Schachter 1982; Skog and Duchert 1993;
Wilson 1992). Outcomes from treat-ments are complex and not
well represented by a simple success-versus-failure dimension
(Marlatt et al. 1988; Mermelstein et al. 1991).
3. Individuals who present for treatment can best be considered selfchange failures who differ in their previous change histories and
who are at different points in the cycle of change described by
DiClemente and Prochaska (1982, 1985; Prochaska and
DiClemente 1992) as the stages of change. Current behavior and
attitudes toward changing a particular behavior as well as prior
attempts to change it that are represented in these stages are
critical dimensions for understanding the current status of any
substance-abusing client applying for treatment (DiClemente
1993a, 1993b).
4. The therapist is a broker attempting to bring treatment and client
dimensions together in the service of the process of change. The
metaphor of a coach or midwife may best characterize the
therapist's role in the recruitment, retention, and participation of
substance abusers in treatment (DiClemente 1991). Figure 2
illustrates the complex, interactive nature of the relationships
among therapist, client, treatment, and change process.
5. Successful long-term change of substance abuse problems
represents the ultimate goal of treatment and interventions of all
kinds. However, this goal is the culmination of a process that is
best understood as a cyclical and spiral movement through the
stages of change (Prochaska et al. 1992).
134
Treatment Compliance or Adherence
Treatment compliance is best defined as the client following the
instruc- tions and requirements of the treatment. In this sense it is a
rather restricted series of events. The client is asked to attend a
certain number of ses-sions, come in regularly to pick up methadone,
get regular urine screens, take disulfiram on a regular basis, stop using
drugs and/or alcohol, go to 90 Alcoholics Anonymous (AA),
Narcotics Anonymous (NA), or Cocaine Anonymous (CA) meetings
in 90 days, and so forth. All of these are measurable events and
observable means of determining whether the client was exposed to a
dose of treatment or the active treatment ingredients thought to be
responsible for the change.
Dose of treatment is closely associated with compliance. Did the
individual take the medication as prescribed, attend the sessions
required? There is clear evidence that dose is related to positive
outcomes from treatment. Stark (1992) reviewed compliance issues
and concluded that treatment completers in alcohol and drug
treatment have more positive outcomes and changes than dropouts.
Similarly, Anglin and Hser (1992) have shown that increased
retention yields better outcomes both in terms of drug use and
decreased criminal behavior for different types of treatments.
135
Simpson (1984) found that length of time in treatment was an
important predictor of outcome for the more than 6,000 clients in
the Drug Abuse Reporting Program (DARP) followup research.
Hubbard and colleagues (1989) found that time in treatment was one
of the most important predictors of successful drug abuse treatment in
their Treatment Outcome Prospective Study (TOPS) of more than
6,500 clients. Moos and associates (1990) found that amount of
treatment predicted outcome for alcoholics. Emrick and fellow
researchers (1993) found that frequency of AA attendance and other
measures of participation in AA activities were correlated positively
with drinking behavior outcomes. Compliance and dose of treatment
do seem related to success in modi-fication of substance abuse
behaviors. However, relapse rates posttreat-ment for treatment
completers are still very high and treatment comple-tion does not
ensure success (Brownell et al. 1986; Hubbard et al. 1989; Simpson
1984).
It is easiest to equate compliance with change only when the active
ingredients are either pharmacological or biochemical and do not
involve intentional behavior change on the part of the client. If a
particular medi-cation or drug substitute like methadone is taken as
directed, then the desired effects are expected to follow directly and
consistently. However, even in these cases, the correlation between
the execution of the prescribed behavior and subsequent change is not
always large. Individuals who take disulfiram have reported learning
to drink over the disulfiram; Moos and colleagues (1990) found that
the number of days disulfiram was taken correlated only -0.23 with
alcohol consumption and 0.17 with abstinence. Drug abusers who
submit to regular drug screens have become very sophisticated in
figuring the odds of detection for certain types of consumption.
Individuals have gone to hundreds of AA meetings to fulfill court
requirements without ever stopping drinking. Emrick and associates
(1993), in their synthesis of 13 research studies, found that frequency
of AA attendance correlated on average 0.19 with drinking behavior.
In fact, a cab driver whom one of the authors met at a conference on
AA reported that he had been court ordered to attend AA for 1 year.
Not only did he comply with this order, but he attended for another
entire year without ever stopping drinking. The bottom line is that
compliance is often easy to measure but is not always a marker of
behavior change with regard to the target problem behavior.
136
Treatment Involvement
Treatment involvement is more difficult to assess, but it is often a
better prognostic indicator of engagement in the process of change
(Orlinsky and Howard 1986). It is axiomatic that individuals who
report using treatment strategies, reading treatment materials, doing
homework assign-ments, and being active and engaged in group or
individual sessions have better treatment outcomes than those who do
not (Simpson et al., in press). Treatment involvement is more than
treatment compliance. The indi-vidual who is involved is engaged in
the treatment process, often has bought into the treatment rationale,
and has formulated goals consistent with the treatment philosophy
and the therapist’s perspective (Sanchez-Craig 1990; Sobell and Sobell
1986-1987). One would expect that indi-viduals who are involved
may be developing better working relationships with the therapist
(Horvath and Luborsky 1993). Treatment satisfaction has also been
related to participation and retention in treatment (DeLeon 1984;
Hubbard et al. 1989). Thus involvement is a valuable intermediate
measure of treatment outcome because it is associated with a host of
positive indicators predictive of treatment success. It is important,
how-ever, to understand what links involvement to successful
outcome.
Treatment involvement will not be a complete predictor of outcome
success unless nonspecific factors of treatment are totally responsible
for the outcome of treatment, as has been proposed by several
researchers (Frank 1973; Luborsky et al. 1975; Sloane et al. 1975) to
explain how different treatments often yield the same or similar
outcomes when com-pared in clinical trials. If all that is needed for
treatment success is a client engaged and participating in a nonspecific
process called therapy, then participation should be highly correlated
with success. This is not the case. Even with an intensive
examination of the treatment alliance seen as a critical common
variable, the relationship between measures of the therapeutic alliance
and outcome is in the 0.30 to 0.35 range (Horvath and Luborsky
1993).
There are several complicating factors in linking involvement with
success. First, many researchers believe that it is the active
ingredients of the treatments, not simply the nonspecific factors, that
influence success in treatment. As has been seen in other chapters,
most researchers are rather committed to a particular treatment
perspective and are not satis-fied with a common factors solution.
Evidence also exists that indi-viduals who receive placebo treatments
137
do not always fare as well as the active treatments (Lambert et al.
1986). Thus, common factors may not be the complete answer to
common outcomes. Second, involvement can be a marker of the
client's desire to please but not necessarily to change. All therapists
have experienced the very compliant client who seems to be doing
everything asked except changing the problem behavior.
Finally, involvement in treatment assumes that the suggested critical
activities of the treatment are actually the needed ingredients for the
client to successfully change or cease the substance-abusing behavior.
This is a rather large assumption. The treatment would have to
provide most of what is needed by this client at this particular time to
make successful change, which would seem to represent and require a
rather sophisticated and individualized treatment matching. One must
either believe that treatments operate uniformly, a suggestion refuted
by Kiesler (1966) and Paul (1967), or there must be a substantial
effort at individualizing treat-ment. However, most treatments are
not highly individualized and tend to offer the same general program
for all who enter that treatment. If there is any sophisticated
matching, it tends to be done by the client in choosing or refusing the
treatment offered.
THE PROCESS OF CHANGE: STAGES, PROCESSES, AND LEVELS
Over the past 15 years, a group of investigators has been examining
the process of change and outlining a transtheoretical model of
behavior change particularly as applied to the modification of
addictive behaviors. Although the model began as an attempt to
provide an integrative, eclectic framework for the excessive
proliferation of psychotherapies (Prochaska and DiClemente 1984),
the vast majority of the preliminary research using the model focused
on tobacco addiction, alcohol depen-dence, and a host of cancer
prevention-related behaviors (DiClemente 1993a; Prochaska and
DiClemente 1992; Prochaska et al. 1992). Only recently has the
model been used with illegal drugs of abuse (Abellanas and McLellan
1993; Shaffer 1992; Washton 1989). However, the authors’ group of
researchers believes that this model contains some critical dimensions
of the process of change needed to understand how individuals
successfully change various behaviors (Prochaska and DiClemente
1992). This model will be used to describe important aspects of the
process of change.
138
The Stages of Change
The stages of change represent the temporal, motivational, and
developmental aspects of the process of change. In terms of
recovery from drug or alcohol dependence, the process would begin
with the pre-contemplation stage in which individuals are too
unwilling, unable, or unknowing to acknowledge drug or alcohol
consumption as a problem or to seriously consider changing their
behavior. Once individuals begin to consider their addictive behavior
to be problematic and to realize that change may be needed, they
enter the contemplation stage. Here they consider the pros and cons
of the behavior and may decide that there is no problem; that there is
a problem but they cannot or will not take action; or that there is a
problem and they need to do something.
The decision to take action and a proximal intention to implement
that decision moves an individual into the preparation stage. Here
the focus is on increasing commitment and making a plan to modify
the drug or drinking behavior. Sometimes that plan is made with the
realization that cessation or abstinence is the goal. At other times
the individual will simply plan to moderate the behavior. In either
case, the implementation of the plan initiates the action stage of the
process of change.
As everyone who has been involved with addictive behavior treatment
knows, entering action does not guarantee long-term success. In fact,
the transtheoretical model describes the action stage as continuing for
3 to 6 months. This amount of time is needed to begin to establish
either sobriety and abstinence from drugs and alcohol or successfully
moderated behavior if the latter is possible. However, real recovery
can only be measured by long-term success that lasts for years rather
than months and represents the maintenance stage of change.
The path of recovery requires movement from precontemplation
through contemplation and preparation in order for an individual to
take effective action and arrive at maintained abstinence from
alcohol and drugs or maintained nonproblematic drinking. For most
individuals the path is not straight and narrow but circular in nature.
Relapse and recycling through the stages constitute the rule rather
than the exception (Brownell et al. 1986; Prochaska and DiClemente
1992). Relapse experiences contribute information and feedback that
can facilitate or hinder subsequent progres-sion through the stages of
change. Individuals may learn that certain goals are unrealistic,
certain strategies are ineffective, or certain environ-ments are not
139
conducive to successful change. Most individuals will require several
revolutions through the stages of change to achieve successful
recovery from any type of addictive behavior.
The stages can be related to the constructs of readiness or resistance
to change that are often used in treatment. The concept of denial is
ubiqui-tous in the literature. It is often assumed that once alcohol
dependence (physiological) is established, denial of the problem and
resistance to change are automatic. However, the stages offer a
sequential path that begins with the lack of acknowledgment that the
behavior is problematic or that change is needed (precontemplation)
but moves through several stages before expecting significant action.
Denial thus becomes part of the process of change.
The stages of change model also provides a perspective on what has
been called spontaneous recovery in the treatment literature
(Tuchfeld 1981). The process of recovery is a cyclical one in which
individuals often make several attempts on their own to modify or
cease their alcohol consump-tion or other problem behavior before
requesting any formal treatment. Thus, clients who present for
treatment can best be considered self-change failures. If there are
failures, it should not be surprising that there are also successes (i.e.,
individuals who recover from abuse or dependence with minimal or no
formal assistance). Therefore, it is important to understand not only
the current stage of change for an individual but also to under-stand
how often this individual has been through the cycle, either alone or
with earlier treatment, to more accurately address his or her needs.
Processes of Change
The importance of the stages of change from a treatment perspective
lies in the fact that strategies and activities to promote change differ
signifi-cantly across the stages. Individuals in different stages utilize
different, specific processes of change (DiClemente et al. 1991;
Prochaska and DiClemente 1985), and process activities vary
systematically with stage status. Certain types of activities peak in
frequency at different points in the cycle of change (Prochaska et al.
1991).
Most theories of therapy or recovery identify one or two critical
processes. For example, acknowledging powerlessness, social support,
skills development, behavioral self-control, contingency
management, and motivational strategies have all been mentioned as
the critical components of successful recovery from alcohol
140
dependence. The transtheoretical model, because of its eclectic
perspective, has identified 10 or more specific processes that can be
utilized at one or more stages in a change process (see table 1). These
processes represent cognitive, affective, behavioral, and
environmental activities that appear to account for the principles of
change proposed by the major systems of therapy, and that seem to
cluster into two larger second-order factors. One repre-sents a
cognitive-experiential component and the other a behavioralenvironmental component, and the processes have been identified in
studies examining smoking cessation, exercise adoption, weight loss,
alcohol abstinence, and general psychotherapeutic problems
(Prochaska and DiClemente 1992).
The interaction of the stages and processes is one of the most
intriguing aspects of the transtheoretical model (DiClemente et al.
1991; Prochaska and DiClemente 1984). Different processes peak in
frequency of use at different points in the cycle of change.
Cognitive-experiential processes are generally most used in the early
stages of contemplation and prepara-tion, while behavioral processes
are most employed in the action and maintenance stages (Prochaska
et al. 1991). However, the cycle is not as simple as it may sound at
first. Higher use of certain processes at some stages actually predicts
relapse (DiClemente and Prochaska 1985).
Processes can be used to control or modify smoking behavior rather than to
stop smoking behavior (Rossi et al. 1988). One recently completed study
demonstrated that shifts in process activity representing use of the right
processes at the right time actually predicted smoking abstinence (Perz et al.
1992). Thus, differential process activity needs to be carefully orchestrated
across the stages to produce successful and lasting change.
Levels of Change
Whenever one speaks of recovery from alcohol or drug dependence, the focus
is on a single target behavior—alcohol or drug consumption. In a
laboratory or an ideal world, the best strategy would be to isolate this one
problem and focus on getting the individual to utilize the processes
necessary to successfully negotiate the stages of change and reach stable
maintained change or recovery. In the real world of drinking and drugs it
is quite impossible to hold constant all the problems that can cooccur.
Because isolation is impossible, it is important to identify problems in
various areas of the individual's functioning in order to develop a realistic
change or treatment plan (DiClemente and Gordon 1983). In the
141
TABLE 1. Processes of change: Definitions and representative
interventions identified in the transtheoretical model.
Process
Consciousness
raising
Self-reevaluation
Self-liberation
Counter
conditioning
Stimulus control
Reinforcement
management
Helping
relationships
Emotional
arousal and
dramatic relief
Environmental
reevaluation
Social liberation
Definitions
Increasing information
about the problem
Assessing how one feels
and thinks about oneself
with respect to problem
behaviors
Choosing and
committing to act or
believing in ability to
change
Substituting alternatives
for anxiety related to
addictive behaviors
Avoiding or countering
stimuli that elicit
problem behaviors
Rewarding oneself or
being rewarded by others
for making changes
Being open and trusting
about problems with
people who care
Experiencing and
expressing feelings about
one's problems and
solutions
Assessing how one's
problems affect the
personal and physical
environment
Increasing alternatives for
nonproblem behaviors
available in society
142
Interventions
Observations, confrontation
interpretations, bibliotherapy
Value clarification, imagery,
corrective emotional
experiences, challenging
beliefs and expectations
Decisionmaking therapy,
New Year's resolutions,
logotherapy techniques,
commitment-enhancing
techniques
Relaxation, desensitization,
assertion, positive selfstatements
Restructuring one's
environment (e.g., removing
alcohol or fattening foods),
avoiding high-risk cues,
fading techniques
Contingency contracts, overt
and covert reinforcement, selfreward
Therapeutic alliance, social
support, self-help groups
Psychodrama, grieving
losses, role playing
Empathy training,
documentaries
Advocating for rights of the
repressed, empowering,
policy interventions
transtheoretical framework, this issue is addressed by the
identification of five levels of change (Prochaska and DiClemente
1984).
Levels of change represent areas of functioning in which an individual
may be experiencing significant problems or conflicts (Prochaska and
DiClemente 1984), and the levels help to identify how many and how
serious the associated problems are for this individual. The levels and
some examples of associated conflicts or problems appear in table 2.
The symptomatic/situational level is the most obvious one. Here,
alcohol or drug consumption is usually viewed as a behavioral problem
as well as a symptom of the alcohol or drug dependence syndrome.
But anxiety, depression, psychotic delusions, and delirium tremens are
all symptoms that can appear at this level, as can homelessness and
other situational problems. There can be multiple problems at each
level as well as multiple problems at multiple levels.
TABLE 2. Levels of change involved in initiation and cessation of
addictive behaviors.
Level of change
I.
Areas of functioning
Substance use pattern
Sympt
omatic/situational
Micro- and macroenviromnemtal factors
Expectancies
II.
Malada
ptive
Beliefs
Self-evaluation
Dyadic interaction
III.
Interpe
rsonal conflicts
IV.
and systems conflicts
Family
Hostility
Assertiveness
Family of orgin
Legal
Social network
Employment
Self-esteem
V.
Interpe
143
rsonal conflicts
Self-concept
Antisocial personality
Maladaptive cognitions represent problems in beliefs or selfstatements that may interfere with recovery. Interpersonal conflicts
are another level that may or may not be related to the targeted drug
or alcohol problem. For many alcohol- or drug-dependent individuals,
relationships with spouse or significant other is quite problematic and
can contribute to recovery or to continued drinking or drugging.
Families, employment, and social systems are yet other areas in which
conflicts can and often do occur. The family and systems level offers
a framework for identifying such problems. Finally, the intrapersonal
conflicts level offers a view of deep-seated, characterological areas
such as narcissism or self-hatred that may be related to recovery.
The levels of change offer a framework for identifying significant
problem areas. However, this is not an exercise in discovering
pathology or etiology. In terms of the process of change, problems
are to be identified that can interfere with an individual’s being able to
move through the stages of change and achieve the maintenance stage
of recovery. Thus, while it may be an interesting exercise to see how
many problems can be generated for one individual, the only relevant
ones are those that will interfere with change and successful recovery.
IMPORTANT INTERACTIONS BETWEEN THE STAGES OF CHANGE
AND THE COMPLIANCE AND INVOLVEMENT OF CLIENTS IN
TREATMENT
This section offers several clear implications of viewing the process
of change as distinct and interactive with retention, compliance, and
participation. Figure 3 illustrates the possible interactions between
treatment participation (compliance and involvement) with readiness
and movement through the stages of change. Individuals in the far
upper right-hand quadrant represent treatment successes. Those in
the lower right-hand corner are successful changers who did not
participate in or comply with treatment. High compliers with
treatment who do not change the problem behavior fit in in the upper
left-hand quadrant of the figure. The figure offers a template with
which to view these implica-tions. At the end of each implication,
strategies to address these concerns in the service of increasing
retention, compliance, and participation are described.
144
Lack of Readiness for Change
Individuals coming to substance abuse treatment are often in early
preaction stages of change. Concepts such as denial and hitting bottom, as
well as the dramatic dropout rates in most substance abuse treatment
programs (particularly outpatient ones) support this contention (Agosti et
al. 1991; DeLeon 1984; Emrick et al. 1993; Rees 1985; Simpson and Joe
1993; Wickizer et al. 1994). Lack of engagement and very early dropout
from treatment are most probably related to the early-stage status of the
clients in the process of change (Miller 1985). As a consequence,
strategies and approaches must address the lack of motivation for change,
ambivalence about change, lack of a clear problem focus, and the
decisionmaking tasks and cognitive experiential processes that characterize
the tasks and challenges of these early stages (DiClemente and Prochaska
1985; Miller and Rollnick 1991; Prochaska and DiClemente 1984;
Prochaska et al. 1994a, 1994b).
145
Suggested Strategies
1. Responding quickly to requests for treatment can maximize
whatever motivation is present at the initial request.
2. It is important to focus on client's immediate concerns, not those
of the program. Such immediate concerns of the drug-abusing
client are the entree to whatever possibilities there are for change.
3. Decisional considerations about the problem and about the
prospective change must be assessed. Clients must begin to see
change as in their best interest before they can move from early
stages toward action.
4. An objective, caring, and respectful approach is essential: Clients
can pick up disrespect even if they are intoxicated, and
confrontation often results in denial (Miller and Sovereign 1989;
Patterson and Forgatch 1985).
5. Objective feedback about the problem and the process of change
can help clients, many of whom can become uneasy when the
therapist is more invested in their change than they are. Lack of
objective and accurate feedback makes the treatment provider
unbelievable and not worthy of trust (Miller et al. 1992).
6. Motivational strategies that focus on the individual and his or her
immediate environment can be effective (Miller and Rollnick
1991).
Matching Treatment and Stage
Stage-based matching of interventions offers a dynamic, process-oriented
approach for developing appropriate treatment expectations and shared
mutual goals on the part of therapist and client. Choosing interventions
based on stage of change with regard to a specific problem can create a
focused working relationship and promote the use of strategies that reflect
the client's most immediate tasks in moving toward successful change.
Treatment matching that is typically viewed as the connection of stable
characteristics of the client with those of the intervention must be
replaced with a dynamic matching perspective. Because the client is
involved in an ongoing process of change, the intervention should mirror
the process.
146
Suggested Strategies
1. The therapist should identify the stage of change of the client and
gather other related information (processes of change, decisional
balance, and self-efficacy considerations). Such information can
help in developing an indepth understanding of the client that will
be helpful in changing the substance-abuse problem or problems.
2. There must be stage-specific feedback systems to guide the client
and/or therapist. Feedback systems can simply reflect current level
of problems and solutions or provide more intensive normative and
ipsative comparisons during the course of treatment (Velicer et al.
1993).
3. The therapist should develop or use approaches and information
specific to each stage (DiClemente 1991).
Relapse and Recycling
Individuals move through the stages of change in a cyclical pattern over a
long period of time. Relapse and recycling are an integral part of the
process of change. Although any single treatment may not create
maintained, successful abstinence or modification of the problem, the goal
of each treatment should be to promote and accelerate movement through
the stages and contribute to the overall process of change in a positive and
constructive manner.
Suggested Strategies
1. The client's recent and past course of movement through the
stages of change should be evaluated.
2. The therapist should adjust approaches for different earlier
patterns of stage movement and change experiences (DiClemente
et al. 1992).
3. To the extent possible, treatment should be individualized.
4. Treatment goals should be realistic: A three-session evaluation
program for precontemplators may be very realistic; a 3-month
program may be more appropriate for someone in preparation or
action. The ideal is sequencing and shifting treatment goals as the
client progresses through the process of change.
147
5. The therapist should keep in mind that much of the movement
through the stages occurs outside the context of the treatment
sessions. Often treatment only provides assistance through certain
stages of change.
6. It is important to be aware of stage heterogeneity in the group
treatment process. Individuals in different stages can often either
facilitate or hinder each others’ progress through positive and
negative modeling as well as by focusing on appropriate or
inappropriate issues (Prochaska et al. 1994a).
Different Stages for Diverse Problems
Individuals can be at different stages of change with different substances
and problem areas. Programs that assume that the client's motivation
parallels the specific stated goals of the treatment program are unrealistic.
Different stages of dealing with multiple problems pose a significant and
serious obstacle for treatment. Treatment personnel can get stuck arguing
about problem areas where the client is less motivated and lose track of the
ones where the client is most committed and ready for change
(DiClemente et al. 1992).
Suggested Strategies
1. The therapist should be aware of varying levels of motivation in
different problem areas.
2. Treatment goals should be chosen carefully and take advantage of
current motivations for change and the leverage for achieving it
provided by the different problems.
3. For clients with multiple problems, multiple diverse strategies are
needed to address varying levels of motivation (Prochaska and
DiClemente 1984).
4. The challenge should be to help individuals do the right thing at the
right time in dealing with each of the problems or problem areas.
Shifting Strategies for Stage Progression
A good, generic therapy relationship can help or hinder the process of
change. The treatment relationship as well as the treatment strategies
should shift as clients progress through the stages. A warm, caring, totally
accepting relationship can be interpreted by the client as supporting
148
problematic behavior. A confrontational relationship can create denial
and resistance.
Suggested Strategies
1. The focus should be on the client's responsibility for change (Miller
et al. 1992).
2. Realistic self-assessment should be supported.
3. Relational strategies can be shifted as clients move through the
stages of change (Norcross 1993).
These suggested strategies are simply possible approaches that could
improve retention and participation in treatment. Some offer common
sense strategies that are intuitively obvious, some are supported by
previous research on factors related to attrition and dropout, and others
have solid research findings supporting a particular suggestion. All of the
suggestions, however, are based on the interaction of the stages of change
with the process of engaging and keeping a client in treatment and
fostering participation based on the process of change.
SUMMARY AND CONCLUSIONS
Current perspectives on compliance and involvement in treatment often
overlook the fact that treatment occurs in the context of a process of
change and not vice versa. Each individual moves at a unique pace through
a series of stages of change and in a cyclical fashion over a substantial
period of time. Treatment personnel and programs should recognize the
diversity of stage status in their clients and address each one in a manner
compatible with the client’s current stage of change, the tasks needed to
move forward in the process of change, and an under-standing of the
course of change. Such considerations should assist the therapist in
developing strategies to increase the engagement of a wide variety of
clients, to improve retention of these clients in a realistic course of
treatment, and to foster participation in stage-appropriate tasks that
promote successful movement through the stages to sustained, long-term
change.
149
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ACKNOWLEDGMENTS
Some of the research and theorizing reported in this chapter was
supported by a grant from the National Institute on Alcohol Abuse
and Alcoholism (U10 AA08432-01). The authors would like to
acknowledge the contribu-tion of the members of the Change
Assessment Research team at the University of Houston who offered
ideas and critiques of the chapter.
AUTHORS
Carlo C. DiClemente, Ph.D.
Professor and Chair
Department of Psychology
University of Maryland, Baltimore County
5401 Wilkens Avenue
Baltimore, MD 21228-5398
Carl W. Scott, Ph.D.
Chair
Department of Psychology
University of St. Thomas
Houston, TX 77204-5341
156
The Role of Family and Significant
Others in the Engagement and
Retention of Drug-Dependent
Individuals
M. Duncan Stanton
Family factors have been part of the drug abuse lore at least since
Fort's early (1954) paper commenting on the parents of heroin
addicts. Subse-quently, the literature on family variables in the
process and treatment of drug problems has shown steady and
increasing accumulation; there were nearly 400 such publications
between 1954 and 1978 (Stanton 1978), and that total would appear
to have at least doubled by now (Heath and Atkinson 1988; Kaufman
1985; Mackenson and Cottone 1992; Sorenson 1989; Stanton 1988).
While there have been publications and some solid research both on
the marital relationships and on the children of drug abusers, the
literature has preponderantly dealt with drug abusers in regard to their
families of origin (e.g., their parents, siblings, and grandparents). This
is partly because drug abusers have tended to be younger than
alcoholics, for instance, and only a minority are married (Cervantes
et al. 1988).
INVOLVEMENT WITH FAMILY OF ORIGIN
Living Arrangements and Frequency of Family Contact
Early views of drug-dependent individuals tended to characterize them
as loners—people who were cut off from primary relationships and
living a kind of "alley cat" existence. It was not until researchers
began inquiring about addicts' living arrangements and familial
contacts that the picture began to shift. For instance, Vaillant
(1966), in a followup of New York narcotic addicts returning from
the Federal narcotics rehabilitation hospital in Kentucky, found that
90 percent of the 22-year-olds whose mothers were still alive went to
live with them, while 59 percent of the 30-year-olds with living
mothers either resided with them or with another female blood
relative such as a grandmother or a sister. A study in Detroit by Ross
(1973) found that addicts (43 percent of whom were female) tended
to operate out of two addresses, one of which was drug related and the
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other family related, and were as likely to provide one as the other, or
both, on admission to a treatment program. Perzel and Lamon
(1979) found that among a group of New Jersey heroin addicts and
polydrug abusers (age range 18 to 53, mean 30 years; 48 percent
female), 45 percent of the former and 42 percent of the latter lived
with a parent—figures that were substantially higher than the 7
percent reported by a normal comparison group.
Whether or not drug abusers actually live with their parents, the
evidence that has accumulated indicates that most are closely tied to
their families. For instance, in tracking addicts for long-term
followup, Bale and colleagues (1977) noted that these clients usually
have a longstanding contact person such as a parent or relative, and
Goldstein and associates (1977) reported that addicts "tend to utilize a
given household (usually their parents') as a constant reference point
in their lives" (p. 25). The authors give examples of how even the
street addict either regularly or periodically gets in touch with his or
her permanent address, renews relationships with family, and the like.
Further, Coleman (personal communication, March 1979), in a
review of 30 male addicts' charts, noted that the person they
requested to be contacted in case of emergency was invariably the
mother, and was almost never the person with whom they lived (i.e.,
wife or girlfriend) for clients who did not live with their mothers.
Finally, a Philadelphia study of 696 opioid addicts, ages 20 to 35,
found that over a 30-month intake period 86 percent of the addicts
reported seeing one or both of their parents face-to-face at least
weekly (Stanton 1982).
A deficiency in most of the above-mentioned studies is that they
asked only about face-to-face contacts, neglecting to inquire about
telephone calls, letters, discussions with siblings that got conveyed to
parents, and such. Addicts are frequently tied to the family system at
many points, so that communication between them and other
members is often routed through siblings, relatives, and spouses.
Asking only about face-to-face contact provides inadequate
information about the (not common) addict who talks to his or her
mother on the phone every day or two for an hour or more. In fact,
Perzel and Lamon (1979) found that 64 percent of heroin addicts and
51 percent of polydrug abusers were in daily telephone contact with a
parent, compared to 9 percent of normals.
Most of these studies dealt with either opioid addicts or polydrug
abusers. The question arises whether the same pattern holds for
individuals who are cocaine dependent. Three studies examined that
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population. Douglas (1987) compared matched groups of male opiate
addicts, cocaine-dependent individuals, and nondrug abusers, aged 20
to 40 (N = 90), and found opiate abusers were in face-to-face or
telephone contact with their parents twice as often, and cocaine
abusers three times as often (i.e., aver- aging four times per week), as
the nondrug-using controls. In a study of fifty 30- to 42-year-old
male opiate/cocaine abusers, Bekir and colleagues (1993) found 82
percent to be "in constant contact with their family of origin by
phone or visiting. Eight visited daily" and 32 (64 per-cent) visited at
least once weekly (p. 628). Further, 5 of the 12 married patients and
their spouses each lived with their own families of origin and only
visited each other. Finally, preliminary data have recently been
gathered from 27 cocaine-dependent males and females (mean age
33.5, range 23 to 51; 61 percent noncaucasian) by the author and
colleagues at the University of Rochester Medical Center. Of those
with at least one living parent or parent surrogate (i.e., someone who
raised them), 78.3 per-cent reported being in at least biweekly
parental contact, and 56 percent in at least weekly contact at the
time of treatment intake.
In a review of the studies on this topic, Stanton (1982) noted that the
pattern is not restricted to North America. Reports from other
countries have arrived at the following percentages of drug addicts
who live with their parents: England—62 percent; Italy—80 percent;
Puerto Rico—67 percent; Thailand—80 percent.
To be sure, most of the reports on this phenomenon derive from
clinical populations rather than untreated drug abusers. However,
Rounsaville and Kleber (1985) found no difference between untreated
(community) addicts and those seeking treatment in terms of familysocial problems. They did, on the other hand, obtain ratings
indicating better functioning of community addicts in regard to
relationships with the extended family. Whether this translates into
more regular or less regular contact is unclear, because the
investigators did not inquire about family contact.
Combining subsequent investigations of family contact with those
included in Stanton's (1982) aforementioned review leads to a clear
conclusion: 26 of 28 reports attest to the regularity with which most
drug-dependent people entering treatment are in contact with one or
more of their parents or parent surrogates. The two dissenting
reports issued from Vancouver, British Columbia and San Francisco.
The former study was later recanted by its author, while the second—
in which 28 detoxi-fying addicts were interviewed—was directly
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challenged 12 years later by Cervantes and colleagues (1988) on a
sample more representative of the San Francisco addict population.
Of the 26 confirming reports, all indicate that a clear majority of
such patients are in at least weekly con-tact, while (depending on
geographical location and other variables) from 35 percent to 80
percent either live with or see one or more parents daily.
Relevant Family Dynamics
Of course, living with or regularly contacting parents is not in and of
itself pathognomonic. In fact, such practices are the rule in some
ethnic groups. The development and maintenance of addiction in a
family member stems from other family variables as well as
nonfamily influences.
To this point, there is a body of research that independently
corroborates the family contact studies and additionally examines the
intrafamily processes relevant to drug dependence (Kaufman 1985;
Mackensen and Cottone 1992; Stanton 1979). Some examples from
this literature should help to clarify.
Madanes and associates (1980) administrated the Family Hierarchy
Test (in which stick figures representing family members are moved
about on a board) to families with an addict, a schizophrenic patient,
or a high-achieving normal. The families of addicts were four times
as likely as those with a schizophrenic disorder, and five times as
likely as the normals, to place figures on the board so that they
actually touched or overlapped. Over half of these instances for
addict families were cross-generational (i.e., between a parent and
child) as opposed to being close connections between those in the
same generation (i.e., spouses and siblings). The implication is of
alliances between an offspring and one parent against the other
parental figure—a finding that also emerged in a study of families of
alcoholics by Preli and Protinsky (1988). Madanes and colleagues
conclude that their data add to the accumulating evidence that addicts
"are enmeshed in dependent relationships with their families of origin
or parental surrogates" (p. 889).
In an Australian study, Schweitzer and Lawton (1989) asked male and
female opiate- and polydrug-dependent patients to complete a
Parental Bonding Instrument. The subjects rated their parents,
especially fathers, as being more cold and indifferent than did
comparison groups, as well as grading them as intrusive and
preventing independence. These results conflict somewhat with a
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study by Ben-Yehuda and Schindell (1981), in which 70.2 percent of
male and female methadone patients in Chicago rated their family as
warm, 61.7 percent said they had a good childhood, and 70.2 percent
felt they had a satisfactory relationship with their parents. Whether
the differences between these two studies are due to culture, type of
treatment program, the nature of the questionnaire, or other factors
is not clear.
ENGAGEMENT IN TREATMENT
The Problem
It has become generally recognized that a very small proportion of
people with problems in drug dependency or abuse are actually
engaged in treatment or self-help groups. Nathan (1990) estimated
the figure to be 5 percent, while Frances and associates (1989) set it
at 10 percent. An epidemiological study by Kessler and associates
(1994) indicated that only 8 percent seek help within a given year.
Given the magnitude of the untreated population and the increasing
contribution of drug abuse (through intravenous use and prostitution)
to the spread of acquired immunodeficiency syndrome (AIDS), the
means for engaging such people in treatment begins to assume signal
impor-tance. Indeed, Frances and Miller (1991) have stated that the
addiction field's "major challenge is helping substance abusers to
accept and continue treatment" (p. 3; italics added).
Clearly, there is a need for procedures that both reach drug abusers and
facilitate their induction into treatment or self-help groups. One
approach that has received fairly wide use is the launching of an
outreach effort. For instance, newspaper articles and announcements,
television/radio public service announcements, personal appearances
by staff, and other techniques have been used by treatment programs,
churches, and com-munity organizations to induce substance abusers
to get help (e.g., Orford 1987; Shapiro 1985; Stockwell 1991). Such
efforts do tend to facilitate the direct engagement of a certain number
of substance abusers, if for no other reason than that the abusers are
made more aware of what is available and that there is hope for
recovery.
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Approaches to Engagement Through Family Members and
Significant Others
Next to legal coercion (Collins and Allison 1983), one of the most
potent avenues for engagement is through meaningful or significant
others, such as spouses, parents, siblings, children, friends, clergy, and
employers. As Resnick and Resnick (1984) put it, "...[T]he family
can often be the key to forcing the patient to stop denial and
avoidance and begin dealing with the cocaine problem" (p. 723). This
author is aware of seven research teams or clinical groups that have
taken a systematic approach to engaging sub-stance abusers, and these
are described below. It should be noted that the thrust here is toward
engaging the abusers themselves, not necessarily their family
members: The induction of families has been reviewed elsewhere
(e.g., Stanton and Todd 1981; Stanton et al. 1982; Szapocznik et al.
1988; Wermuth and Scheidt 1986).
Intervention. Originally developed in the 1960s by Johnson (1973,
1986) at the Johnson Institute in Minneapolis, intervention is a
method for mobilizing and rehearsing family members, friends, and
associates to confront the alcoholic with their concerns, strongly urge
him/her to enter treatment, and lay out the consequences (such as
divorce, loss of job) if he or she refuses. Interveners usually prepare
in secret, using the element of surprise. Although the approach has
mostly been applied with drinking problems, it has also been adapted
for other chemical dependencies (Liepman et al. 1982).
Despite its widespread use, very little research has been undertaken on
intervention. A search of "Psychological Abstracts" and
"Dissertation Abstracts International," scanning the years since 1980,
located only two studies, both of a preliminary nature (Liepman
1993); these are described below.
Using a quasi-experimental design, Liepman and colleagues (1989)
reported on 24 cases in which an average of 4 people per case took
part in preintervention counseling and/or confrontation of the
alcoholic. Six of the seven alcoholics who were actually confronted
entered (outpatient) treatment. However, 17 cases never reached the
point of confrontation; they never engaged in treatment. In other
words, the approach was successful in 25 percent of the total number
of cases.
Logan (1983) combined intervention methods with the social
network therapy approach of Speck and Attneave (1973) and
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Garrison (Callan et al. 1975; Garrison et al. 1977). Each intervention
network involved the 8 to 12 individuals deemed most important to
the alcoholic. Of the 60 interventions attempted over a 1-year
period, 54 (90 percent) resulted in the alcoholic entering treatment.
Community Reinforcement Training (CRT). This method spun off the
original community reinforcement approach (CRA) to alcoholism
treatment developed by Azrin and colleagues (Azrin 1976; Azrin et al.
1982; Hunt and Azrin 1973; Meyers and Smith 1995) and has been
applied to cocaine dependence by Higgins and associates (Higgins and
Budney 1993; Higgins et al. 1993, 1994). CRT involves seeing the
distressed family member (usually the spouse) the day that he or she
telephones in to get help for a drinker. It also requires being available
during nonworking hours and off days in case the family member
reaches a crisis point when the drinker requests help. The program
includes a number of sessions with the spouse in which checklists are
completed and the spouse is taught how to avoid physical abuse,
encourage sobriety, encourage the seeking of treatment, and assist in
treatment. The approach is generally nonconfrontational and
attempts to take advantage of a moment when the drinker is
motivated to get treatment by immediately calling a meeting at the
clinic with the counselor, even if it is in the middle of the night
(Sisson and Azrin 1993). Sisson and Azrin (1986) examined
effectiveness of this approach with 12 cases—7 in which a family
member received CRT and 5 in which the person received traditional
(Al-Anon) type counseling. In six of the seven CRT cases, the
alcoholic entered treatment, while none of the traditional cases did.
Berenson’s Approach. Berenson developed a method for working
with the most motivated family member or members to get the
alcoholic into treatment and Alcoholics Anonymous (AA) (Berenson
1976; see also Stanton 1981 for more detail). This approach
strategizes with the spouse and works toward helping him or her
detach from the drinker. While this approach has several fairly clearcut stages and a number of specific techniques that could be codified in
a manual, no research has yet been undertaken with it.
Unilateral Family Therapy. This approach, developed by Thomas and
associates (Thomas and Ager 1993; Thomas and Yoshioka 1989;
Thomas et al. 1987), has been applied with spouses (usually wives) of
uncoop-erative alcoholics. The therapist meets with the spouse over
some months, with a focus on spousal coping, reducing the abuser’s
drinking, and inducing the abuser to enter treatment. The method was
influenced by intervention and CRA, although the intervention used is
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normally by one person (the spouse) and termed a "programmed
confrontation." By the fifth month, some open attempt (or a series
of attempts) is made to get the drinker into treatment. At 6 months
from first spouse contact, 39 percent of the drinkers in the group in
which the spouse was treated immediately (versus a delayed condition)
had entered a program, compared with 11 percent for the delayed
group. When other cases were added in which the drinkers had not
entered treatment but had achieved and maintained "clinically
meaningful" reductions in their drinking levels, the percentages were
57 percent and 37 percent, respectively (Thomas and Ager 1993;
Thomas et al. 1990).
Co-Operative Counseling. Yates (1988) described an experimental
program in England using "affected others" to enlist alcoholics in
treatment. The effort began with an active outreach component to
get people to call the program. Over the 6-month period studied,
calls were received from family members and others regarding 30
cases, three-quarters of whom had never been in treatment for their
drinking. In 11 cases, the caller (and, of course, the drinker) never
came in, while in 4 more the caller came for one visit but the drinker
was not engaged. Five more did not want the drinker to know they
had contacted the agency. Of the remaining 10, 4 actually entered
treatment. However, five others reduced their drinking markedly,
even without being formally inducted. In sum, 13 percent of the
original 30 got into treatment. Of the 19 cases when the caller
actually came in, 21 percent entered treatment and 26 percent
reduced their drinking, meaning that 47 percent either showed up or
showed improvement once the affected other appeared in person.
Strategic Structural Systems Engagement. A method for engaging
adolescent substance abusers (and their families) has been developed
by Szapocznik and colleagues (1988). They defined six levels of
engagement effort by a therapist receiving a call about a prospective
client. The levels ranged from minimal joining with, and inquiry of,
the caller, to higher level "ecological" interventions—involving not
only the family, but other relevant systems, such as the school and
health center—and out-of-office visits to family members. The
choice of level depended on the sort of resistance encountered; the
authors identified four types. In 90 percent of the call-ins the caller
was the mother of an adolescent drug abuser, so the telephone
conversation usually concerned how she could get the adoles-cent and
other family members in for treatment. Using this method,
Szapocznik and colleagues were able to get 93 percent of the targeted
adolescents to come to the clinic with their families for an intake
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meeting, compared to 42 percent for an engagement-as-usual
condition.
The Albany-Rochester Interventional Sequence for Engagement
(ARISE). Devised by Garrett of the Al-Care program (a sizable outpatient facility for substance abusers in Albany, NY), ARISE entails
several stages in the mobilization of family and significant others
toward patient entry (Garrett et al., submitted). It combines formal
intervention (Johnson 1973, 1986), social network therapy (Speck
and Attneave 1973), and the (integrative) Rochester approach to
family and network therapy (Landau-Stanton 1990; Landau-Stanton
and Clements 1993; Seaburn et al. 1995; Stanton 1984; Stanton and
Landau-Stanton 1990). In essence, the method is an attempt to draw
upon what are considered to be the strongest features of each of these
approaches as well as some techniques from a few other therapeutic
schools.
Developed with both alcoholics and drug abusers, the method evolved
in response to three particular limitations of the more standard,
formal intervention. First, an intervention requires considerable
expenditure of time and effort, since it involves a good deal of
instruction, the writing and public reading of letters to the substance
abuser, rehearsal, and other activities, and it was felt that a sizable
proportion of callers might not require something so ambitious and
expensive.
A second reason for expanding engagement options was that confrontation can be very frightening to family members, possibly assuming
the flavor of an ultimatum (Lewis 1991). Often the problem drinker
is controlling things in the home—sometimes tantamount to a reign
of terror—and the family is not ready to oppose him or her. In fact,
if pushed too hard by professionals, the family may simply abandon
the effort. Thus, a slower, nonescalating, less distressing induction is
called for, at least initially. It can attract some families who are not
prepared to risk a full-blown intervention.
Third, data by Loneck and colleagues (in press) coupled with clinical
experience indicate that, although patients who undergo a formal
intervention are as likely to complete treatment as those who do not
experience intervention, they are twice as likely to relapse during the
process. It is not clear to what this interesting conundrum should be
attributed—it may be a rebellion against being coerced—and the
subject is currently under investigation.
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The ARISE model consists of three general stages. Each stage
involves an increased commitment of therapeutic and
familial/network resources compared to the stage that precedes it.
The procedure is as follows.
Stage 1: Informal Intervention Without a Therapist Present. A
concerned person calls the clinic, perhaps in response to an outreach
effort or a friend’s recommendation. He or she is worried about a
family member or an acquaintance who has a drinking problem and
either has not sought help or refuses to do so. The caller wants the
person to enter treatment, and may even request a formal
intervention. (For purposes of this discussion, the drug-dependent
person is called the "DDP.") Upon hearing the caller’s request, the
receptionist contacts the intervention specialist on call, who either
takes the call or gets back to the caller later that day.
As the 15- to 30-minute conversation unfolds, the specialist tries to
determine who is in the family, who is in the natural support system,
and what other people might be key. Related to this, the specialist
also begins to clarify to the caller why it might be helpful and
preferable to include all these other people in the induction effort.
Sometimes this stage takes more than one telephone conversation,
but rarely more than two. By the end of the talk(s), the specialist
wants to have: (a) identified the important players and secured a
commitment for them all to be invited to come to the clinic together;
(b) set a time for the meeting; (c) made it clear that the DDP is also
to be invited; (d) estab-lished that even if the DDP agrees to come,
and then backs out at the last minute, everyone else should come—
that it would then be a kind of evaluation appointment involving
coaching and strategizing as to how to persuade the DDP to come in.
Stage 2: Informal Intervention With a Therapist Present. It is AlCare’s experience that, following a telephone conversation such as
that described above, about 90 to 95 percent of the time at least one
person (but usually several, or many more) shows up for the first
meeting. At that point, a chart is opened on the case. Normally the
therapist who attends this meeting is the same person (the
intervention specialist) who conducted the telephone interview.
The major agenda at this stage is, of course, to plan and strategize in
detail as to how to get the DDP to enter treatment. Family and
friends often hesitate to have a full-fledged confrontation, and the
therapist guides discussion by statements such as, "We want to do
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something that’s really caring, and shows that you’re worried."
However, the therapist wants to keep the process moving, and will
usually make a pitch to call the DDP directly right then, from the
meeting.
This stage unfolds over a sequence of one to three sessions. Each
session is viewed as an opportunity to bring in the DDP. If, after
three (or, occasionally, four or five) such meetings, the DDP is not
engaged in treatment, the therapist moves to the third stage—a
formal intervention.
Stage 3: Formal Intervention. This format is based on the Johnson
Institute model briefly described earlier. However, it is a kinder,
gentler, less negative approach—a direction also taken in later years
by the Hazelden Foundation and even by the Johnson Institute itself.
In addition, the approach incorporates a number of elements from the
Rochester therapy model, including attention to the intergenerational
patterns of the alcohol problems. That it has been utilized to get
patients into both outpatient and inpatient treatment (including
detox) has made it generalizable to a great many treatment contexts
and made it particularly appealing to managed health care systems.
ARISE Engagement Data. Loneck and associates (in press)
performed a retrospective analysis of engagement and retention in
332 Al-Care cases from the past 6 years. The full complement of
cases was scanned for that period and all cases were categorized in one
of five entry categories: The three ARISE stages (N = 195), plus
those who were coerced to enroll (through probation, employee
assistance programs, attorney, or other sources; N = 68), and those
who enrolled on their own, without coercion or some level of
intervention (N = 69). From this pool, approximately equal numbers
of cases were randomly selected from within each category to allow
comparisons. To be eligible for this study, all cases came in for at
least one evaluative (get acquainted) meeting. For the cases dealt with
through ARISE, this meant that one or more significant others
attended the first meeting.
Most of the cases (258) were alcohol problems. For purposes of this
chapter, attention will be given to the remaining 74 cases, who were
drug (primarily cocaine) abusers. The percentages of cases in which
the DDP entered treatment for each of the three ARISE stages were,
respectively: stage 1 = 45 percent; stage 2 = 59 percent; stage 3 = 92
percent. Fifty-five percent were in some phase of the ARISE process.
Although lower than the 70 percent level attained for alcoholics, this
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rate compares favorably with the percentages of DDP treatment
inductees attained through coercion (50 percent) or self-referral (also
50 percent). Given that the coercion and self-referred cases were,
almost by definition, more motivated to enter treatment, the fact
that ARISE achieved nearly equal results with resistant, highly
ambivalent drug users (i.e., people who wanted nothing to do with
treatment) is a testament to its utility. This point is perhaps further
strengthened when one realizes this was not research therapy, with all
the added benefits that might accrue to such (Weisz et al. 1992), but
was conducted in a community clinic with no obvious expectation
that, years later, engagement efforts would be scrutinized.
Conclusions. It is difficult to make definitive statements, given the
scant number of studies, with generally small numbers, that have
addressed this issue. The range in success rate is also wide: for
intervention, it stretched from 25 percent to 92 percent. Two
variables do give tentative indica-tions of importance, however.
First, it would appear that the greater the availability of the
counselor—for instance, after hours and on weekends— the more
likely the DDP is to be caught at the right moment and induced to
enroll.
The second dimension has to do with the size of the group of
significant others collected for the intervention. Logan (1983) had
twice as large a group assembled than did Liepman and colleagues
(1989) (i.e., eight people versus four), and attained at least three
times the success rate (90 percent versus 25 percent). The perhaps
obvious (but still tentative) conclusion is: The more people gathered,
the more potent the effect.
RETENTION IN TREATMENT
Recently, the author has been engaged in reviewing the controlled
studies of family treatment for drug abuse (Stanton and Shadish,
submitted). To date, 15 such studies have been conducted that used at
least two comparison/control conditions and random assignment. An
issue that has arisen from this effort pertains to whether the analysis
of outcome for a given study incorporates all subjects assigned to
treatment conditions, or only those who received some minimal
amount of a treatment regimen. These different approaches derive
from two different questions (Howard et al. 1990). The first is,
"What are the expected outcomes for a group of clients assigned to a
given treatment, whether or not they fully engage in or complete that
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treatment?" The second question is more limited in scope: "What
outcomes can be expected among those who receive (or partially
complete) a given treatment?" In their influential and by now classic
review of methodological problems in research on treatment of the
addictions, Nathan and Lansky (1978) have taken a strong position
on this question, stating that to exclude such dropouts is, whether
intended or not, a deception, and that such cases "should be considered
treatment failures regardless of the rationalizations some
[investigators] may have given for the decision to terminate" (p.
717).
Differential Attrition Rates
A major area of concern emerges from this research: differential
dropout rates for different treatment conditions. In those studies
comparing family/marital therapies to nonfamily approaches, almost
without exception the nonfamily conditions had higher dropout rates.
Put another way, significantly more family therapy cases stayed in
treatment compared to nonfamily cases. For instance:
• 33 percent of Friedman's (1989) parenting group cases never
engaged in treatment (versus 7 percent of the family therapy
cases);
• Joanning and associates (1992) had dropout rates of 53
percent, 33 percent and 13 percent, respectively, for peer group
therapy, family psychoeducation, and family therapy; and
• Liddle and colleagues’(1993) respective dropout rates for peer
group therapy, multifamily therapy, and (conjoint) family
therapy were 49 percent, 35 percent and 30 percent.
Therefore, this pattern warrants attention because, as Howard and
colleagues (1986) note, it can serve to undermine the effects of
randomi-zation.
Stark (1992) reviewed the literature on substance abuse treatment
dropouts and concluded that "the fact that clients who use more drugs
have higher attrition rates is true almost by definition and is
overwhelm-ingly confirmed by the evidence" (p. 102). Stated
differently, heavier drug-taking, poorer-prognosis patients (i.e., those
at the less treatable end of the spectrum) are more likely to drop out
early. Consequently, a therapy (call it treatment A) that incurs fewer
dropouts is likely to be retaining a higher proportion of these less
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tractable, possibly harder core (less motivated?) clients. Treatment A
is thus left with the task of bringing about changes in an overall
tougher group than, say, treatment B, because more of the "toughies"
will have already defected from B. Consequently, if the outcome
results of A and B are, for example, equal, A would have done it in the
face of more difficult odds—like two people starting and finishing a
foot race at the same time in which one of them additionally carries a
60-pound pack.
A specific example might illustrate. In a study by Stanton and
associates (1984), 164 incoming methadone maintenance patients
were deemed eligible for the research, signed agreements to
participate, and were randomly assigned to one of two conditions (84
to family treatment and 80 to nonfamily), both of which at least
initially involved methadone. However, because those members of
the research team who administered methadone treatment felt that
less than 2 weeks on methadone would be an unfair test of the
efficacy of that modality, it was decided that only subjects would be
retained in the study who remained on methadone for 14 days or
more. As it happened, 55 patients defected before 14 days had
elapsed, leaving 109 in the study. The problem was that a
disproportionate number of them (35) came from the nonfamily
condition, compared to 20 from the family condition, resulting in
disparate dropout rates of 44 percent versus 24 percent. Whether or
how this might have altered outcomes for the two groups cannot be
determined, but it seems likely that if any effect came into play it
would more likely be an adverse one for the family condition. In any
case, such a problem cannot necessarily be overcome statistically,
such as by introducing pretreatment covariates into an ANACOVA
design, because it is difficult to know the key variables that are
operating.
There is a certain irony when a treatment approach that effects
better retention is penalized by being compared with modalities with
lower retention rates. The problems in the aforementioned example
could have been prevented by following Nathan and Lansky's dictum
of including everybody in the analysis, that is, all 164 initial subjects.
But of course that would have incited protest from other quarters
(which might also have jeopardized support from the funding agency).
Nonetheless, it appears that in a number of the studies reviewed by
Stanton and Shadish (submitted), true differences between treatment
conditions may have been obscured because the conditions differed in
their attrition rates, and dropouts (and deaths) were not included as
failures in the analyses. (In fact, a subsequent analysis by Stanton and
170
Shadish of the Stanton and associates’ 1984 data, but with dropouts
and deaths included, found that the family therapy condition did
indeed yield significantly better results at the 0.01 probability level.)
In the future, more researchers will need to take steps to account for
or eliminate differential dropout rates among treatment conditions to
avoid unnecessary confounding and ambiguous results.
Difficulties With Adult Clients
Getting adult opioid addicts to engage and remain in any kind of
psychotherapy study has been notoriously difficult. Among
controlled individual psychotherapy studies with this population, the
rates tend to be low for eligibles who are contacted, agree to
participate, and remain for a minimal period of, say, 3 weeks, ranging
from 5 percent (Rounsaville et al. 1983) to 36 percent (Woody et al.
1983). In contrast, the rates for successful retention of adult patients
in family therapy, as shown by the four studies that provided such
data (out of five total), are: McLellan and colleagues 1993—73
percent; Stanton and associates 1982—71 percent and 1984—76
percent; Ziegler-Driscoll 1977—53 percent. The mean retention rate
across the four studies, weighted by sample size, is 66.6 per- cent,
which is almost twice the rate for the most successful individual study
and 13 times larger than the least successful.
Some Explanatory Factors and Processes
Why the difference in retention between family and other types of
treatment? At least part of the explanation may lie in the way that
treaters handle real world events in a client's life (i.e., those occurring
outside the treatment center). Such events assume special significance
for people who are closely tied to their families of origin, as was
earlier noted to be the case with the majority of drug abusers. Three
areas, in particular, merit consideration.
The Family Life Cycle. A study of U.S. Army personnel who go
absent without leave (AWOL) brings a different light to the issue.
Hartnagel (1974) found that over half of AWOLs do not leave
because they hate the Army. Rather, they are family problem solvers
who go AWOL to correct family problems or to alleviate familyrelated financial difficulties. They go home to help. If they had a
choice, they would rather be granted leave to go home, take care of
business, and then return to their military duties.
171
It is the contention here that family problems (which, incidentally,
are usually associated with family life-cycle events) can also provide
motivation for drug abusers either to relapse or to abort treatment.
For instance, there is evidence that onset of drug abuse and overdoses
can be precipitated by family disruptions, stresses, and losses (Duncan
1978; Krueger 1981; Noone 1980). Further, the disruptions may not
obviously involve the client directly, but may be of a more indirect
nature (such as when his or her mother loses a boyfriend, or father
loses a job). However, like the AWOL soldier, the drug abuser
responds to the larger family crisis. Such a pattern is, of course, most
likely to manifest itself with clients who are in residential programs
and therefore physically less available to their family members.
The Family Addiction Cycle. Stanton and colleagues (1982) and
others have noted a cyclical pattern in families of addicts in which,
when the addict improves in some way, the parents begin to fight and
to separate from each other. When the addict fails by taking drugs or
losing a job, the parents come together around him or her; they
involve themselves and each other with the addict's problems, thus
becoming, in a sense, unified. In this way the addict's behavior serves
a purpose of at least temporarily keeping the family together.
Further, from this viewpoint, the drug-taking is simply one event
within an interpersonal sequence of behavior; it is not an independent
phenomenon occurring in a vacuum, but a response to a series of
others' behaviors that precede (and succeed) it. That is the reason for
the term "family addiction cycle."
Treatments that are not attuned to such sequences in a client's life put
themselves at a disadvantage. They run the risk of being constantly
mystified by onset and cessation of drug-taking. By not appreciating
the plight of both the addict and his or her family members, they also
risk losing their client's trust.
Triangulation. Some years ago Schwartzman and Bokos (1979)
published a paper on a competitive process they observed taking place
among drug treatment programs in a large city. Patients would appear
at, say, program D requesting admission and complaining about
treatment they had received at program C. The staff person at the
new program would then commiserate with the client, disparage
program C, and give assurance that no such problems would crop up at
program D, where "we treat our clients right." Thus an interpersonal
triangle would be established, with two of its parties (the client and
program D) joined in opposition to the third (program C). This
process has been termed "triangulation." It is common, to at least
172
some degree, in most interpersonal systems. (Schwartzman and
Bokos also noted, incidentally, that in many cases the client would
eventually become disenchanted with program D and would defect
either back to program C or to a new program, thus setting up a new
triangle and repeating the process.)
Likewise, staff in drug programs have been known to fall into the trap
of triangulation vis-a-vis a client's parents or family members. This is
a particular risk for individual-oriented approaches to therapy.
Campbell (1992) performed a content analysis of therapists' writings
regarding their patient's family members and found that 90 percent of
the time family members were referred to in negative terms. In a
description of an effort to expand their drug treatment program to be
more inclusive of parents and families, Balaban and Melchionda
(1979) reported that staff often got into awkward and destructive
triangles in which they would compete with a client's family over the
client—at times reaching the point of open disparagement of the
parents or even fostering defection from the family.
When binds of this sort occur, they can put tremendous pressure on
clients. Torn between their loyalties to parents or family members
versus treatment staff, clients may choose an option that relieves the
pressure: aborting treatment. For this reason, and with apologies to
Hippocrates and grammarians, it may then be wise, when attempting
to engage and retain drug abusers in treatment, to subscribe to the
oath "First of all, do no triangulation."
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AUTHOR
M. Duncan Stanton, Ph.D.
Professor of Psychiatry (Psychology)
University of Rochester School of Medicine and Dentistry
300 Crittenden Boulevard
Rochester, NY 14642
180
Establishing and Maintaining a
Therapeutic Alliance With Substance
Abuse Patients:
A Cognitive Therapy Approach
Cory F. Newman
INTRODUCTION
A positive, collaborative therapeutic relationship is an essential
component of the cognitive therapy of substance abuse (Beck et al.
1993). To engage substance abuse patients in treatment, therapists
will need not only to connect with the patients but also gain their
trust. Otherwise, the patients will be less likely to benefit from
treatment, and their rates of no-show and dropout are apt to increase.
Therefore, therapists must work diligently to form a working alliance
by demon-strating general good will and a respectful desire to help.
Further, they must carefully attend to any signs that the patients are
losing interest or having adverse emotional reactions, and intervene
promptly.
COMMON OBSTACLES TO FORMING A THERAPEUTIC ALLIANCE
Substance-abusing patients are an especially difficult population with
whom to establish a commitment to change. A glance at the troubled
family life of a substance abuser is instructive. At the height of his or
her use of drugs, a patient often obtains far more gratification from
the drugs than from the love and companionship of significant others,
friends, and relatives. Therefore, the positive social reinforcement
from a supportive therapist may pale in comparison to the high that
the patient gets from a line of cocaine or a hit of crack. Thus, the
therapist's capacity to act as an agent of change is more limited and
fragile than with many other patient populations for whom the
therapist’s approval and guidance have greater relative significance.
As a result, the therapist will need to build the relationship when the
patient is in a period of diminished drug use or abstinence. During this
time, the benefits of having meaningful interpersonal relationships
should be underscored at the same time as the drawbacks of drug use
are being highlighted. The intention of this strategy is to enhance the
181
patient's perceived reasons for remaining drug free, to motivate the
patient to strive for relationship preservation, and to communicate
the kind of therapeutic support that the patient will value.
Additionally, substance abusers often enter treatment with
ambivalence about relinquishing their habits (Carroll et al. 1991a,
1991b; Havassy et al. 1991). Within the framework of Prochaska
and colleagues' (1993) stages of change model, one sees that many
substance abusers do not enter treatment at the stages of action or
maintenance. Instead, they commence therapy with a notion that it
might be beneficial to give up the use of drugs, or with a wavering
desire to cut back on their use (i.e., the contem-plative stage). In
extreme cases, such as when patients are remanded by the courts to
attend drug abuse rehabilitation sessions, the patients may not
acknowledge that they have a problem with drugs or even that they
use them at all (the precontemplative stage).
From the very start, therapists will need to ascertain their patients'
respective levels of commitment to change in order to have the best
chance of communicating an empathic understanding and to minimize
the risk of pushing an unwanted agenda onto patients whose resistance
then will likely increase. It is generally not a good idea to accuse
patients of "not really wanting to change," or of "wanting to suffer,"
or of "being in denial" (Newman 1994a). It is one thing to confront
patients in this manner when they are in the protective confines of
an inpatient (perhaps group therapy) setting. It is quite another to do
this in an individual outpatient setting where the patient can easily
leave treatment and never return if he or she takes offense at the
therapist's methods. It is far more preferable to acknowledge that the
patient has mixed emotions, and then to assess and get to know the
part of the patient that likes to use drugs and the other part that
would rather be free of them. In this manner, the therapist
demonstrates that he or she is not so naive as to believe that the
patient's goal is unequivocal and immediate abstinence, but instead to
recognize the complexities and difficulties involved in trying to stop
using drugs. Further, the therapist avoids the potentially damaging
pitfall of communicating in a judgmental, unempathic tone.
182
ESTABLISHING RAPPORT AT THE OUTSET OF TREATMENT
The initial interactions between the patient and therapist are
extremely important, as substance abuse patients often will be silently
sizing up their therapists to determine whether they can be trusted and
know what they are doing (Perez 1992). The lack of a positive start
to treatment may lead a patient to choose not to return for further
sessions, or may foster negative expectancies in the patient that
often exacerbate passive resistance or contentious behavior in session.
On the other hand, a positive start to treatment may instill hope in
the patient, thus encouraging him or her to stay in treatment and to
consider the prospects of therapeutic change more seriously.
The following are some common methods by which therapists can
connect with their substance-abusing patients as treatment begins:
1.
Speak directly, simply, and honestly.
2.
Ask about the patient's thoughts and feelings about being in
therapy.
3.
Focus on the patient's distress.
4.
Acknowledge the patient's ambivalence.
5.
Explore the purpose and goals of treatment.
6.
Discuss the issue of confidentiality.
7.
Avoid judgmental comments.
8.
Appeal to the patient's areas of positive self-esteem.
9.
Acknowledge that therapy is difficult.
10.
Ask open-ended questions, then be a good listener.
Speak Directly, Simply, and Honestly
The development of rapport is hindered when patients cannot
understand their therapists due to the therapist’s unbridled use of
psychological jargon. Similarly, patients often do not appreciate it
when they perceive that their therapists are talking down to them, or
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are speaking to them in the manner of a teacher addressing a grade
school class.
The remedy is to endeavor to speak adult to adult, rather than
authority to subordinate. For example, the cognitive therapist would
be ill-advised to speak in the following manner: "I'll be assessing your
thought processes so as to spot the kinds of cognitive distortions that
lead you to engage in dysfunctional and antisocial activities."
Instead, the therapist might say: "If it's okay with you, I'd like to
understand your point of view about things. I don't want to assume
that I already understand what it's like to live your life. I'm interested
in listening to your thoughts so I get the real story."
Although the therapist in the second example does not really start
teaching the patient about cognitive therapy, he or she establishes
some of the groundwork. More important at this early stage, the
therapist comes across as being a real person who is understandable.
As the patient progresses through succeeding sessions, the therapist
will be able to elaborate gradually on the specifics of cognitive
therapy, and to teach some of the basic nomenclature.
Additionally, it is important for therapists to share their own
thoughts and opinions openly (and diplomatically) when patients ask
for them, rather than remaining mysterious figures. Substance
abusers, either by virtue of their own developmental/personality issues
or their experiences with dishonest drug-abusing associates, often have
major problems in trusting others. A therapist who makes an earnest
effort to respond to questions can provide the patient with evidence
that the therapist does not have a hidden agenda. As a qualifier to the
above, it is important to note that the therapist should feel free to
ask the patient many questions as well, lest the patient put the
responsibility for the work of therapy entirely (and inappropriately)
on the therapist.
Ask About the Patient's Thoughts and Feelings About Being in
Therapy
The therapist should assume neither that the patient is highly
motivated for treatment nor that he or she is resistant and hostile.
The best way to obtain valid data and at the same time demonstrate
that the therapist cares to understand how the patient feels is to ask
the patient directly about his or her experience of coming to the
therapist's office.
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Such questions can involve asking about the patient’s doubts and
concerns, as well as expectations, goals, and hopes for therapy. If the
patient expresses misgivings about being in treatment, these negative
reactions can be addressed on the spot, thus reducing the risk of early
dropout. At the same time, the therapist can utilize this interaction
to begin to teach the patient the cognitive therapy model. For
example, a patient who expects to be disrespected by the therapist
may harbor feelings of anger. By contrast, if the patient expects to
be helped, he or she may feel a sense of relief and have a high degree
of motivation. This example begins to demonstrate one of the
central tenets of cognitive therapy, namely, that the patient's
thoughts will influence his or her feelings, intentions, and actions.
Focus on the Patient's Distress
In light of the high rates of dual diagnoses in substance abusers who
present for treatment (Castaneda et al. 1989; Evans and Sullivan
1990; Nace et al. 1991; Rounsaville et al. 1991), it is likely that these
patients will be suffering from affective disorders, anxiety disorders,
or other psychological maladies when they enter treatment. If
therapists show an interest in sympathizing with and addressing these
emotional problems, in contrast to focusing exclusively on the
substance abuse per se, they can demonstrate that they are interested
in the entirety of the patient's well-being. In this manner, therapists
show that they are interested in getting to know the patient as a
person, and not simply as an addict.
Such an approach is especially indicated for substance-abusing patients
who also meet diagnostic criteria for antisocial personality disorder
(ASPD). These patients typically are unmotivated to change unless
they are in emotional distress, in which case there is a desire to
participate in therapy to gain relief (Alterman and Cacciola 1991;
Woody et al. 1990). By helping these ASPD/depressed drug abusers to
improve their mood, therapists may be able to form an interpersonal
alliance with patients who otherwise might not bond with a helper.
Even when patients do not technically meet criteria for dual
diagnoses, they may often experience emotional suffering related to
having reached points of crisis in their lives (Kosten et al. 1986;
Newman and Wright 1994; Sobell et al. 1988). Therefore, it is quite
appropriate for therapists to put such topics as current areas of stress
and family problems on the thera-peutic agenda. In addition to
providing the patients with understanding and empathy, this approach
also calls patients' attention to the fact that substance abuse is an
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important cause of their general malaise in life. This may further
motivate patients to consider the cessation of substance abuse as a
major goal of treatment.
Acknowledge the Patient's Ambivalence
Anecdotally, some drug-abusing patients report that they doubt (at
least early on) that therapists who have not had drug problems
themselves can truly understand their patients' plights. However,
upon further questioning, it typically becomes apparent that this
misconception arises when the patients perceive that their therapists
take the view that, "Of course you want to quit using drugs. You have
everything to gain and nothing to lose by becoming clean and sober."
Patients then conclude that their therapists don't understand the
power and allure of drugs such as cocaine.
Therefore, it is advisable for therapists to admit that cocaine is a
difficult drug to relinquish, and that it would be reasonable and
understandable for the patients to have a sense of grief about having
to give up the drug (Jennings 1991). By acknowledging and asking
about the patients' ambiv-alence, therapists communicate more
accurate empathy, and open up a vital area of discussion that patients
otherwise might believe it best to conceal.
In fact, one of the standard techniques in the repertoire of the
cognitive therapist depends on the therapist's awareness of the
patient's mixed emotions and attitudes—the advantages/disadvantages
analysis (Beck et al. 1993). Here, therapist and patient explore the
pros and cons of both using and not using drugs. Many patients
express pleasant surprise that their therapists really are willing to
discuss the pros of continuing to abuse drugs. Although the ultimate
goal obviously is to strengthen the patients' resolve, know-how, and
commitment to be drug free, an exploration of the seductive aspects
of drug use can help the formation of a trusting, collaborative
therapeutic relationship.
Explore the Purpose and Goals of Treatment
Cognitive therapy contains a significant psychoeducational
component (Beck et al. 1979). A long-term goal of treatment is to
empower the patient—to increase a sense of self-efficacy and to
teach the patient to becomes his or her own therapist. One way to
achieve this goal is to make the patient a full partner in charting the
course of therapy. This entails discussing the purpose of meeting with
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the therapist, the goals of treatment, and the types of methods that
will be used to achieve these goals.
By exploring the purpose and goals of treatment, therapists take
some of the mystery out of the process of change, and minimize the
chances that mistrustful patients will view their therapists as playing
mind games or being on power trips. If the therapist and patient
determine that their respective goals are at odds, at least the problem
will be on the table, and not a conflict of hidden agendas. They can
then agree to find some common ground, and work toward shared
goals until the thornier issues can be discussed and explored at greater
length. Therapists can stress that the process of change requires
teamwork, and that the therapist and patient are not adversaries.
Discuss the Issue of Confidentiality
Because illicit drug use is by definition illegal behavior, patients have
learned to be very cautious in what they will divulge about their
activities. Thus they often are highly motivated to be dishonest in
reporting their substance abuse. Although the vast majority of
therapeutic interactions represent privileged communications, drugabusing patients may not understand or trust the extent to which their
admissions of drug use will be kept confidential.
To facilitate more open communication and mutual trust, therapists
should spell out the nature and limits of confidentiality from the very
start. Patients may not be pleased to hear about the limits, but they
will appreciate the explanation and the warning. Therapists will need
to emphasize that their primary role is to help patients confront their
drug use and improve the quality of their lives; therapists do not serve
as society's watchdog, or punish, or oppress.
Avoid Judgmental Comments
A longstanding and well-known fact is that it is important for the
therapist to communicate a sense of positive regard and respect for
the patient (e.g., Bergin and Solomon 1970; Egan 1975; Truax 1963;
Truax and Carkhuff 1967; Truax and Mitchell 1971). Nevertheless,
it is all too easy for the therapist to fall into the trap of sounding
accusatory and judgmental toward a patient who is abusing drugs. If
this happens, the formation of a healthy therapeutic relationship is
seriously hindered. Further, the patient may become less inclined to
view the therapist as an effective professional when the therapist's
comments resemble those heard from exasperated relatives.
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Instead, therapists need to explain that they wish to ally with their
patients in a mutual struggle against the patients' drug use and
concomi-tant life problems. Patients need to be helped to understand
that they are not viewed as bad people, but rather as people with a
highly troublesome habit with which to deal.
Similarly, therapists need to take care not to spew forth judgmental or
hostile comments about anybody else. For example, when a therapist
treats a substance-abusing patient who is involved in a romantic
relation-ship with another substance abuser, there is a great
temptation for the therapist to criticize the significant other,
especially when the significant other sabotages the patient's progress
toward abstinence. However, by doing this the therapist runs the risk
of triangulating the patient between the loved one and the therapist
(in essence, putting the patient in the position of having to take
sides). When this happens, patients frequently choose to be loyal to
the significant other, which may precipitate a flight from treatment.
Even if the therapist makes judgmental comments about impersonal
third parties, the patient may wonder whether this is also how the
therapist truly feels about the patient when he or she is not around.
This will impede the formation and maintenance of a positive
therapeutic alliance. It is much more prudent to evaluate the relative
merits and drawbacks of the behaviors and attitudes of people, rather
than make pat statements about their characters.
Appeal to the Patient's Areas of Positive Self-Esteem
Although substance-abusing patients typically present with a host of
problems, including chaotic lifestyles and skills deficits, it is important
for therapists to assess their patients' areas of strength and
competence. By doing so, therapists show that they have respect for
their patients' individual talents and assets. Further, they can appeal
to areas in which the patients feel a sense of pride, thereby eliciting
greater cooperation in other therapy tasks.
For example, Walter (all names have been changed) was a patient who
was very mistrustful of authority figures, and his collaboration in the
process of therapy at the start of treatment was tenuous at best.
Although he seemed to be quite hostile and resistant, he did prove
himself to be rather intelligent (in spite of his limited education).
When Walter would engage in high-risk behaviors (e.g., drive while
intoxicated), the therapist would appeal to the patient's intelligence
to get him to reconsider this maladaptive behavior. For example, the
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therapist would say: "Walt, you and I have discussed how you have
survived to this point, mainly due to your smarts. You seem to be
someone who thinks fast under pressure. That's why I'm so perplexed
that you would risk your safety and freedom by driving drunk. It just
doesn't seem to fit. What's your opinion about all of this? I'm
interested to hear your views."
Aside from noting the patients' intelligence, therapists can encourage
patients to collaborate in the work of therapy by focusing on other
attributes such as their survival skills, the love of their friends and
family, their spirituality, their integrity, their potential abilities to be
positive role models for others, their advanced vocational skills (when
sober), and other legitimate personal attributes.
Acknowledge That Therapy Is Difficult
Therapists can help to build rapport with their patients by noting that
it takes courage and hard work to participate fully in therapy. This
stance can help to counteract patients' beliefs that it is a sign of
weakness and incompetence to be in treatment. In essence, the
therapist tries to help the patient to take the shame out of being a
patient. Additionally, by establishing the baseline notion that therapy
will be difficult, the therapist reduces the chance that a patient will
bail out of treatment at the first sign of discomfort.
The therapist can liken the pain of going through therapy to the pain
of receiving medical treatment for a wound or a broken bone.
Although the procedures hurt, they enable the patient to heal and to
be strong. The adage, "If it hurts, you know the medicine is working,"
is appropriate in this regard. By contrast, if the patient comes to
learn that he or she actually enjoys and looks forward to therapy
sessions, it will seem like a bonus benefit.
Ask Open-Ended Questions, Then Be a Good Listener
One of the defining features of cognitive therapy is the spirit of
collaboration that the therapist attempts to foster in working with
the patient (Beck et al. 1979). A central method for enhancing an
atmo-sphere of collaboration is to encourage the patient to actively
talk and think aloud in the session, and for the therapist to listen
carefully and reflect accurately. Additionally, it is important to add
structure to this process by asking clinically relevant questions that
allow the patient to expound his or her feelings and thoughts. Openended questions serve this purpose well.
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A common trap to avoid is lecturing the patients and/or bombarding
them with yes/no questions that are reminiscent of interrogation. It
is much more collaborative to employ a Socratic style (Overholser
1987, 1988, 1993) in which the therapist gently guides the direction
of the session material by punctuating the patients' comments with
thoughtful, open-ended questions. The following short dialog serves
as an example.
Therapist: I see on your responses to the questionnaires that you
haven't used any drugs or alcohol since our last session. What
do you think has helped you to do this?
Patient:
I don't go past that house no more.
Therapist: The crack house?
Patient:
Yeah.
Therapist: What do you say to yourself—how do you manage to
keep yourself from going to that house?
Patient:
I just remind myself that my life falls apart
whenever I start to go there. I just remind myself that I'm
kidding myself if I think I can just stop in and say "hi" and
shoot the breeze and then just go home. It don't work
that way. I just have to stay away.
Therapist: So you remember the problems that you had when you
used to go there, and how your life changes for the worse
when you use drugs.
Patient:
That about sums it up. (Frowns)
Therapist: You looked a little sad just then. What went through
your mind?
Patient:
Ahhh. I don't know. (Pause) It's a lonely feeling.
I got friends who hang out at the house, and I can't see
them no more.
Note that in the example above, the therapist gets a lot of useful
information from the patient by asking open-ended questions and by
carefully listening to the patient's responses. A good rapport seems
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to be present in the interaction, with the patient implicitly
acknowledging that the therapist understands.
MAINTAINING A POSITIVE ALLIANCE OVER THE COURSE OF
TREATMENT
It is often difficult to establish rapport and a collaborative working set
with substance-abusing patients; moreover, it is very easy to lose that
rapport once it is there. Therefore, even when things seem to be
going smoothly in the therapeutic relationship, the therapist must be
vigilant in consistently doing what is necessary to maintain the
positive feelings between therapist and patient.
The following are some general principles that therapists can employ
throughout treatment to preserve a productive and healthy
therapeutic alliance.
1.
Ask patients for feedback about every session.
2.
Be attentive. Remember details about the patients from
session to session.
3.
Use imagery and metaphors that the patients will find
personally relevant.
4.
Be consistent, dependable, and available.
5.
Be trustworthy, even when the patient is not.
6.
Remain calm and cool in session, even if the patient is not.
7.
Be confident, but be humble.
8.
Set limits in a respectful manner.
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Ask Patients for Feedback About Every Session
The best cure for a damaged therapeutic relationship is prevention.
One of the easiest and most reliable methods for avoiding
misunderstandings between the therapist and patient is for the
therapist to check on what the patient perceives and feels about the
session. This can be done during the course of the session (e.g.,
"What do you think about what I've been saying so far today?")
and/or at the completion of the session (e.g., "How do you feel about
today's session? Is there anything I said that rubbed you the wrong
way?") If the patient states that he or she is disgruntled, or
demonstrates nonverbal reactions that seem to indicate discomfort
(e.g., sighing, reticence), the therapist can address this immediately,
providing a heavy dose of nondefensive empathy along the way.
For example, one patient misconstrued the therapist's discussion of
high-risk situations as an attempt to plant the idea into the patient's
head that he was going to succumb to his urges. Once the therapist
asked for feedback and ascertained that the patient thought the
therapist was trying to sabotage the patient's sobriety, the therapist
was able to explain his actual intentions, which were to educate and
help the patient. For good measure, the therapist apologized for not
being more clear.
It is important for the therapist not to assume that everything is
okay in the therapeutic relationship just because the patient hasn't
openly complained. Patients who have mistrust issues and/or live in
dangerous neighborhoods often conceal their negative feelings
extremely well. They adopt a "street smile" that hides both their
vulnerability and their desire to strike back without warning.
Therefore, the therapist should make an effort to ask for feedback on
a regular basis, as both a preventive and a reparative measure.
Be Attentive. Remember Details About the Patients From Session
to Session
Although this point may be common sense in theory, it is not always
easy to enact in practice. For example, some drug-abusing patients
may use slang terms the therapist doesn’t know. If the therapist
doesn't ask for clarification, he or she may miss important
information. This may further lead the patient to think that the
therapist didn't care to understand, rather than that the therapist
wasn't able to understand, and the therapeutic rapport may be harmed.
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To accurately conceptualize the patient's life situation, the therapist
must be able to mentally accumulate information about the patient
from week to week. In this way, understanding increases. A simple,
tried-and-true method to enhance this process is to take thorough,
prompt therapy notes about every contact with the patient, and to
review these notes religiously before each new session.
Use Imagery and Metaphors That the Patients Will Find Personally
Relevant
Once the therapist facilitates the establishment of rapport by
speaking "directly, simply, and honestly" (see first item, previous
section), he or she can facilitate more sophisticated understanding by
using images and metaphors to communicate important but complex
points.
For example, a therapist wanted to discuss the patient's tendency to
isolate himself from others, including those who purported to love
him and to want to help him. The therapist conceptualized the
patient's problem in terms of the patient's fear that he would
inevitably hurt anyone who got close to him. Further, the patient saw
himself as being very attractive and powerful, thus making his efforts
to isolate himself from would-be admirers all the more difficult.
The therapist used the following metaphor in order to explain this
formulation, while also appealing to the patient's narcissism: "Joe,
you're like a shiny new Porsche with no brakes. You're coming down
the road looking as cool and swift as you can be, and everyone wants
to come up close to you to get a better look. Meanwhile, you know
that you have no brakes. Therefore, you're afraid if that people get
too close, you're going to run them down, and you're not sure you can
live with yourself if that happens, so you drive away from everybody.
Joe, I think we need to get you some brakes. What do you think?"
Then the therapist elicited feedback from the patient, who said he felt
both understood and complimented. This facilitated the continued
discussion of the important issue above.
Be Consistent, Dependable, and Available
Therapists typically do not earn their drug-abusing patients' trust
through sudden, dramatic gestures. Rather, trust is gained through the
therapist's consistent professionalism, honesty, and well-meaning
actions over a long period of time.
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Although drug-abusing patients often may arrive late for sessions, fail
to show up at all, and otherwise demonstrate the lack of a serious
involve-ment in the process of treatment, therapists (by contrast)
need to demon-strate a steady commitment to helping these patients.
Therefore, it is very important for therapists to arrive on time for
their appointments, even in cases when the patients habitually come
late. In like manner, it is impor-tant for therapists to be available for
therapy sessions on as regular a basis as possible (and to make sensible
alternative arrangements if necessary), to return their patients' phone
calls promptly, and to be reachable in cases of emergency.
Another more powerful way that therapists can establish that they are
well grounded and dependable centering points in their patients' lives
is to unfailingly pursue patients who do not show up for their sessions.
If the therapist establishes a pattern whereby he or she will almost
always telephone a patient within hours of their missing a session, the
therapist communicates a concern that goes beyond words. Along
these same lines, it is advisable for therapists to be willing to continue
to treat a drug-abusing patient when he or she returns after a drug
lapse or other prob-lematic hiatus from therapy. This strategy
provides the most realistic means by which to treat a disorder whose
course is often recurrent. Further, it provides a sense of hope for
patients who otherwise might believe that they have burned their
bridges with all benevolent and helpful others. Therefore, they may
be more apt to return to treatment voluntarily and more quickly
following future lapses.
Be Trustworthy, Even When the Patient Is Not
As explained above, therapists must demand a higher standard of
behavior from themselves than they can expect from their substanceabusing patients. Patients who act and think in combative, passiveaggressive, and/or mistrustful ways in their everyday life often expect
that others will treat them in like fashion. Therefore, it is a
corrective experience for patients when they realize that their
therapists will continue to demonstrate honesty and concern, even
when the patients themselves have been less than friendly or truthful
in return.
As difficult as it is to gain the trust of the substance-abusing patient, it
can be impaired or lost quickly and with relatively little provocation.
There- fore, the therapeutic relationship must be managed in a
delicate, pains-taking fashion. In the process of accomplishing this
194
goal, therapists must recognize their own anger when patients lie to
them, and must strive to keep such feelings in check. Instead,
therapists need to find a diplomatic way to address the "apparent
inconsistencies" in what the patients say and do, and to remain
nonjudgmental (Beck et al. 1993).
Remain Calm and Cool in Session, Even If the Patient Is Not
When a patient becomes hostile, loud, intransigent, and/or verbally
abusive, it does little good for the therapist to respond in kind (Beck
et al. 1993). To deescalate a potentially dangerous situation, the
therapist must stay calm, nondefensive, and matter-of-fact. It is
important at such times for the therapist to express a genuine
concern for the patient's well-being and best interests.
When the therapist and patient are at odds, it is extremely helpful for
the therapist to call attention to their areas of agreement and
collaboration. This helps to remind that patient that a single conflict
with the therapist does not mean that the entire therapeutic endeavor
is adversarial. Although a certain degree of confrontation between
the therapist and the drug-abusing patient is almost inevitable during
the course of treatment (Frances and Miller 1991), the therapist can
minimize damage to the therapeutic relationship by calmly
communicating a tone of respect and concern (Newman 1988).
Be Confident, But Be Humble
One of the most fundamental ways to help patients gain confidence
and hope about the process of therapy is for therapists to show
confidence in themselves. This involves such behavioral components
as clarity of voice, relaxed posture, nondefensiveness, and an
energetic optimism.
However, the therapist does not need to go to extremes to
demonstrate confidence. In fact, it is actually ill-advised for
therapists to portray themselves as omnipotent and/or omniscient. A
certain degree of humility is necessary to create and sustain an
atmosphere of collaboration and mutual respect.
For example, therapists must be willing to admit that they do not
know (or were wrong about) something, if appropriate, rather than
try to fake their way through. For example, one patient repeatedly
referred to a "Reverend Percy" in his first therapy session. At one
point, he asked his therapist, "You're aware of Reverend Percy's work
195
in the community, aren't you?" The therapist, not wanting to seem
like he was ignorant about important civic leaders, was tempted to tell
a white lie and answer "yes." Fortunately, the therapist humbly
admitted that he hadn't heard of Reverend Percy, but that he was
interested in learning more about him. The patient laughed, and
stated that it was a good thing that the therapist didn't know Reverend
Percy, because "I just made him up!" By showing a willingness to
admit that he didn't know something, the therapist passed the
patient's rather clever but devious test. Therefore, the therapist
preserved his credibility.
Another way therapists can demonstrate humble confidence is to
apologize at times. Therapists can do this in response to
misunderstandings or minor errors, such as a miscommunication about
the exact date and time of a scheduled session, or a harsh sounding
comment (e.g., "I'm sorry if my last statement sounded rather hard on
you. Really, I'm on your side, but perhaps I got a little carried away
just then because I was very concerned about you."). The therapist
communicates confidence by showing that he or she is not afraid to
admit to a mistake, and that he or she is still optimistic about the
course of therapy.
Set Limits in a Respectful Manner
While it is important that therapists work collaboratively with their
substance-abusing patients, they must take care not to become so
permissive that patients will know that they can take advantage of
their therapists' good will. Limits must be set (Ellis 1985; Ellis et al.
1988; Moorey 1989)—for example, that a therapy session will not be
held if the patient is intoxicated.
Therapists should establish ground rules during the first session so
there will be no confusion or ambiguity later on. Therapists can set
limits without sabotaging the therapeutic relationship if they adopt a
respectful tone and emphasize their commitment to help patients
with their problems (Newman 1988, 1990).
For example, Beck and colleagues (1993) describe the case of a
patient who arrived intoxicated for a therapy session. The therapist
asked the patient if he had been drinking, and the patient
acknowledged that he had. The therapist thanked the patient for his
honesty and then suggested that the session be postponed. When the
patient protested, the therapist calmly stated, "We made an
agreement that we would meet only when you were sober and able to
196
fully absorb the benefits of the session, and I think we should stick to
our agreements." The therapist went further to point out the
advantages of the patient's remaining in the waiting room for a couple
of hours until it was safe for him to drive home. The patient was a bit
disgruntled, but was mollified when the therapist gave him a
newspaper to read to keep him occupied.
The lesson to be learned from the above vignette is to set limits, but
be neither critical nor controlling. Emphasize that the patient's
welfare is the primary concern, and that the therapeutic alliance is
still active and strong in spite of the disagreement. Then, follow
through.
THE THERAPEUTIC RELATIONSHIP AND THE CASE FORMULATION
Therapists who are most adept at accurately understanding their
patients have the best chance of establishing and preserving positive
alliances with their patients. In this sense, a good case formulation
goes a long way toward helping the therapist and patient maximize
their collaborative effort.
When conflicts arise between a therapist and a patient, and/or when
unexpressed but problematic ill feelings exist in the therapeutic
relation-ship, the therapist can explore aspects of the case
conceptualization to make sense of the interpersonal tensions in
session. Oftentimes, this strategy will not only shed light on the
reasons for the problems in the therapeutic relationship, but will
advance an overall understanding of the patient's life issues. As a
result, important material is revealed, the patient feels better
understood, and the therapeutic alliance is strengthened.
The following are some general guides for using the case
conceptulation in the service of improving the therapeutic
relationship.
1.
Strive to understand the pain and fear behind the patient's
hostility and resistance.
2.
Explore the meaning and function of the patient's seemingly
oppositional or self-defeating actions.
3.
Assess the patient's beliefs about therapy.
197
4.
5.
Assess your own beliefs about the patient.
Collaboratively utilize unpleasant feelings in the therapeutic
relationship as grist for the mill.
Strive To Understand the Pain and Fear Behind the Patient's
Hostility and Resistance
Although the therapist may believe that change is a good thing,
clients may have misgivings. Many patients, especially those with
serious, longstand-ing disorders, cling tenaciously to the status quo in
their lives, because to some extent it is familiar and safe (Beck et al.
1990; Layden et al. 1993; Newman 1994a; Young 1990). For many
patients, it is frightening and disorienting to change patterns of
cognition, affect, and behavior that they have long associated with
their very identity. Additionally, many patients believe that
significant change is untenable, due to further difficulties that they
expect would arise.
For example, Ed and his therapist agreed that prostitutes were a highrisk stimulus for him. Whenever he would encounter a prostitute who
liked to get high, he was vulnerable to seeking out drugs with which to
pay the woman. Then, they would have sex and smoke crack cocaine
together. In spite of this understanding, Ed still frequented prostitutes
and used drugs. At first, this exasperated the therapist, who thought
that Ed was deliberately sabotaging therapy because of an opposition
to change. However, when the therapist probed for Ed's fears about
giving up this maladaptive pattern, Ed was able to articulate that he
felt he had nothing to offer a straight woman. He believed that
because he was unemployed and not very handsome, his only means
of finding female companionship would be in the context of drug use
with a prostitute. In other words, underlying Ed's apparent resistance
was a fear of being alone. This understanding helped the therapist to
express empathy, and to encourage Ed to actively challenge the belief
that he would be alone if he gave up drugs.
When patients become overtly angry in session, therapists can cope
with this situation best by trying to provide empathy, and by
reminding them-selves that no matter how aversive this situation is
for therapists, the patients almost always feel worse. This stance
helps therapists to decatas-trophize the situation, and to keep the
therapists' attention squarely on the patients' needs.
For example, one therapist defused a patient's hostile outburst by
asking, "Do you feel I've let you down in some way?" Another
198
therapist achieved the same end by saying, "I'm sorry if what I've said
or done has upset you. That wasn't my intention. How did what I
said hurt your feelings?" Yet another example is the therapist who
"normalized" his patient's angry refusal to answer the therapist's
questions by stating, "I can see that you're only trying to protect
yourself. That's okay. Everybody has the right to do that."
Explore the Meaning and Function of the Patient's Seemingly
Oppositional or Self-Defeating Actions
When substance-abusing patients do not appear optimally connected
with the therapist or engaged in the process of therapy, it is useful to
explore the factors that seem to make it in the patient’s best interest
to oppose the therapist.
Therapists can address this issue head on by noting that there are both
advantages and disadvantages to changing one's behavior, and that it
might be interesting to look at the pros and cons of attending
therapy, as well as the pros and cons of using or abstaining from drugs.
Therapeutic collaboration is facilitated when therapists show that
they are willing to look at the cons of change (Grilo 1993). Patients
then become more apt to cooperate in the exercise of reviewing the
long-term costs involved in not changing. Thus, patient receptivity
to change is enhanced.
Rita's behavior at the start of therapy was quite contentious. She
contra- dicted or made sarcastic remarks about much of what the
therapist would say. After experiencing much frustration and
consternation, the therapist finally said: "Rita, given that you
frequently disagree with me, my first guess would be that you don't
like to meet with me—and yet, you always come to your sessions.
What are you getting out of these sessions? How is therapy meeting
your needs, given that we seem to be at odds so often?"
Rita didn't know what to make of this at first. Upon further
reflection, however, she admitted that she gained a sense of power out
of being able to intellectually spar with the therapist. In her view, it
would take the fun out of therapy if she agreed with her therapist.
This admission led to a fruitful discussion of power, control, and
counter-control in relationships.
Assess the Patient's Beliefs About Therapy
199
An assessment of how patients idiosyncratically interpret various
situa-tions is part and parcel of the process of case conceptualization
in cogni-tive therapy (Persons 1989). One such situation is therapy
itself. Some patients expect that therapy will be an adversarial
process, especially when they perceive their therapists to be from a
more privileged socio-economic background. Here, they may
perceive their therapists to be agents of the system who will continue
to oppress them. Naturally, this viewpoint is laden with mistrust, and
will need to be addressed in order for treatment to proceed in a
collaborative and amicable fashion.
Another problematic belief about therapy to which some drug-abusing
patients subscribe is that the process should always feel good. This
belief ignores the fact that taking part in treatment is hard work, and
often involves the discussion of emotionally painful issues. If this
belief is unassessed and unaddressed, a patient may bolt from therapy
at the first sign of discomfort, perhaps before a positive therapeutic
alliance can even be established.
Yet another maladaptive cognitive stance that some patients adopt is
that therapists cannot be of any help unless they have gone through
the problem of substance abuse in their lives too. Therefore, instead
of looking at their therapists as positive role models who have the
personal and technical skills to help the patients with their problems,
patients may discount the thera-pists' comments and reject their help
because "they just don't understand."
Therapists need to be aware of some of these (and other)
dysfunctional presuppositions that drug-abusing patients sometimes
have about therapy and therapists. Towards that end, it is extremely
useful in the first session for therapists to ask two series of questions,
one during the early stages of the session and the other at the end of
the session.
The first question is: "What are your thoughts about coming in to
meet with me today? I'm not sure whether you feel good or bad about
seeing me, and I'm not sure what your expectations or hopes about
treatment are. But I'd like to know, if you're willing to share your
thoughts with me."
The second question is: "What are your impressions about how things
went in today's session? Was there anything that I said that you
didn't like or didn't agree with? Was there anything about today's
session that was particularly helpful? What should we make sure we
200
continue to talk about in our next session in order to get the most out
of being here?"
Assess Your Own Beliefs About the Patient
Therapists are human beings, and therefore are subject to their own
dysfunctional beliefs at times. This is most problematic when the
therapist's maladaptive beliefs center on their patients, and the
therapist fails to take stock of these beliefs. Some of the more
commonly encountered therapist beliefs (cf. Beck et al. 1993)
include:
•
"This patient is a loser."
•
"This patient is beyond help."
•
"This patient will never listen to me."
• "Why can't I reach this patient? What am I doing wrong?
I'm going to have to give up on working with this patient."
• "You can't be collaborative with this type of patient. If you
give them an inch, they'll take a mile. Therefore, I will not budge
from my position one iota."
•
"This case is more trouble and responsibility than I can bear."
When therapists find themselves having such thoughts, it presents them with
an excellent opportunity to use cognitive therapy techniques on themselves
(Newman 1994b). This strategy can help therapists moderate their own
hopelessness and frustration enough to still be able to provide good will and an
earnest effort. The end result is that the therapeutic relationship will
continue to have a positive effect on the process of treatment, rather than
being a hindrance. Additionally, the therapist will have gained a deeper
understanding of the nature of the patient's typical interpersonal difficulties
in everyday life.
The following is a sampling of rational response flashcards that therapists can
personally develop to help them modify counterproductive beliefs about drugabusing patients (cf. Beck et al. 1993):
• "There have been a number of sessions in which the patient and I
have worked very well together. Those were rewarding experiences that I
must not forget."
201
• "Let me try to understand my patient's resistant thoughts and
behaviors, rather than simply label her a troublemaker."
• "This power struggle is a great opportunity to get at some really hot
interpersonal cognitions!"
• "If I keep my cool, present my point of view calmly, and also show
that I'm willing to be flexible within reason, I'll probably get a lot more
therapeutic mileage out of this conflict than I will if I become strident or
stubborn."
Collaboratively Utilize Unpleasant Feelings in the Therapeutic Relationship
as Grist for the Mill
Tension and conflict between a patient and therapist need not be gratuitously
disruptive to the process of therapy. In fact, if handled skillfully, such
episodes can shed light on the patient's negative beliefs and actions regarding
interpersonal relationships (cf. Layden et al. 1993). This information, in
turn, can be used to help the patient make important discoveries, and can
inspire him or her to experiment with new adaptive behaviors.
For example, a therapist noticed that the patient was looking glum, not
making eye contact, and sounding a little sarcastic. To explore the meaning
of this behavior, the therapist forthrightly said, "Things seem a little tense
between you and me today. Did you notice that?" This led to the patient's
becoming uncharacteristically silent; therefore the therapist knew that she
had hit home. She added, "Can we talk about it? If something is wrong I'd like
to try to work it out, if that's okay with you."
Upon further discussion, the patient stated that the group therapy
leader (in another setting, though still part of the patient's treatment
package) had said something that "he could only have known if he
spoke to you." In other words, the patient thought that his individual
therapist was saying things about him behind his back to the group
therapy counselor. This, in fact, was not the case at all.
The therapist and patient discussed all the possible alternatives to his
mistrustful point of view, including the possibility that the group
counselor and individual therapist were independently reaching similar
clinical judgments about the patient. The therapist added that she
would certainly talk to the patient directly about the prospect of
sharing information with the group counselor if the need arose. Then
she demonstrated empathy for the patient, stating, "It must have
202
been difficult for you, thinking that I betrayed your trust. I can
imagine how disillusioned you must have felt. I'm glad we can set the
record straight, because I have enjoyed working with you, and things
seemed to be going well until this misunderstanding."
Furthermore, this episode became grist for the mill in that it highlighted one
of the patient's characteristic patterns—namely, to jump to con-clusions
about the ill motives of another person, and then to keep these suspicions to
himself. This would then prevent the possibility of talking things out and
resolving or clarifying the matter with the other person, and the relationship
would deteriorate. It was little wonder that the patient felt he had so few
friends, and believed that he could never depend on anyone. Because the
therapist succeeded in uncovering the nature of the rupture in the therapeutic
relationship, the patient-therapist alliance was preserved, and an important
aspect of the patient's dysfunction became a clinical topic for the session.
CONCLUSION
The treatment of substance-abusing patients poses a great set of challenges
to therapists. One of the most fundamental and vital of these is the establishment and maintenance of a positive therapeutic relationship. If therapists succeed in communicating a spirit of acceptance, collaboration, respect,
good will, and optimism to their drug-abusing patients, the process of
treatment will be enhanced. If, by contrast, these goals are not achieved, the
likelihood of the patients' demonstrating spotty attendance, poor
punctuality, and premature termination will increase, thus diminishing the
prospects that therapy will have an appreciable effect.
Therapists can facilitate the formation and maintenance of a positive
therapeutic alliance with drug-abusing patients by consistently
adhering to principles that are part and parcel of a cognitive therapy
approach. Such principles include working with the patient as a team,
giving clinical rationales in a clear fashion, eliciting feedback from the
patient, exploring the belief systems of the patient, being aware of
one's own belief systems and how they may impinge on the
therapeutic process, and utilizing the case conceptualization and other
strategies that require a thoughtful, empathic, and pragmatic
approach.
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AUTHOR
Cory F. Newman, Ph.D.
Assistant Professor of Psychology, in Psychiatry
University of Pennsylvania
School of Medicine
and
Clinical Director
Center for Cognitive Therapy
University City Science Center
3600 Market Street, Suite 754
Philadelphia, PA 19104-2648
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Back to Basics: Fundamental
Cognitive Therapy Skills for Keeping
Drug-Dependent Individuals in
Treatment
Bruce S. Liese and Aaron T. Beck
INTRODUCTION
Dr. A is conducting his third cognitive therapy session with Mary, a
depressed, cocaine-dependent 34-year-old woman. As she describes a
recent relapse, Mary begins to cry. Dr. A says he has no tissues and
he makes no effort to find any. Instead he urges her to think
carefully: "Now Mary, what goes through your mind right before you
use cocaine?" Mary's crying escalates and in the absence of tissues she
blows her nose and wipes her tears with the wrapping paper from the
sandwich she ate for lunch. Dr. A persists in asking about Mary's
drug-related thoughts. She responds to his queries, but does not show
up for their next two scheduled sessions. Eventually she drops out of
therapy.
Dr. B is meeting with Bob for their second session. Bob, diagnosed
with cocaine dependence and narcissistic personality disorder,
describes himself as "extraordinarily successful and gifted." As
evidence of his brilliance, Bob offers a long list of accomplishments.
Bob doubts whether anyone, including Dr. B, can really understand or
help him. In this session, Bob graphically describes a sexual
encounter. Dr. B interrupts with the question, "What cocaine-related
beliefs were you having at this moment?" Bob responds incredulously,
"What the hell are you talking about?" Dr. B insists that cognitive
therapy will help Bob eliminate the thoughts and beliefs that led to his
drug use. Bob responds, "Good luck!" He never returns to see Dr. B.
Dr. C is conducting his first psychotherapy session with Gina, an
unmarried 18-year-old woman dependent on alcohol, marijuana,
nicotine, and cocaine. Gina explains that she dropped out of school
at age 16 to take care of her newborn baby. She admits to using drugs
when she is overwhelmed. In this first session, Dr. C spends 35
minutes of a 50-minute session describing cognitive therapy. He gives
detailed technical descriptions of schemas, conditional beliefs,
cognitive distortions, facilitative beliefs, and instrumental strategies.
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Dr. C completes his lecture by asking, "Does this make sense?" Gina
replies, "I guess so." Satisfied with this answer, Dr. C finishes his
lecture and schedules Gina for their next session. Gina shows up for
the following session, but attends only a few more sessions before she
eventually drops out of treatment.
For several years, cognitive therapists have been trained to provide
treatment to drug-dependent patients. These case examples reflect
actual incidents observed during this training process. The authors
have witnessed scenarios such as these and realized the extraordinary
challenge and importance of retaining drug-dependent patients in
treatment. This chapter reviews the literature on premature
termination (i.e., dropout). The cognitive model of substance abuse is
presented, along with the authors’ conceptualization of missed
sessions and dropout. And finally, strategies are proposed for
retaining drug-dependent individuals in treatment.
THE LITERATURE ON THERAPY DROPOUTS: A BRIEF REVIEW
A substantial literature addresses the problem of dropout from
psycho-therapy (Wierzbicki and Pekarik 1993). Dropout has been
found to relate to several factors, including quality of the therapeutic
alliance (e.g., Mohl et al. 1991; Grimes and Murdock 1989; Strupp et
al. 1992; Tryon and Kane 1990) and severity of psychopathology
(e.g., Avasthi et al. 1994; Kazdin 1990; Kazdin et al. 1993; MacNair
and Corazzini 1994; McCallum et al. 1992; Ravndal and Vaglum
1994; Sterling et al. 1994). Generally, research has revealed
inconsistent relationships between demographic variables and dropout
(e.g., Beckham 1992; Gilbert et al. 1994; Mosher-Ashley 1994; Sledge
et al. 1990). Nonetheless, in a recent meta-analysis of 125 studies,
Wierzbicki and Pekarik (1993) found significant relationships
between three demographic variables (race, education, income) and
dropout.
A number of studies have demonstrated positive relationships between
substance abuse and dropout from psychotherapy. In a study of 142
outpatients with various psychiatric diagnoses, Swett and Noones
(1989) found that patients with drug or alcohol problems were more
likely than other patients to drop out of individual psychotherapy. In
a study of 65 depressed adolescents, Gilbert and colleagues (1994)
found that those with alcohol and drug histories were more likely to
drop out of a 12-week psychotherapy group than those who did not
report alcohol or drug use. MacNair and Corazzini (1994) studied 155
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university students enrolled in interpersonal therapy groups and found
that those with alcohol and drug problems were more likely to drop
out than those without such problems.
Recently, investigators (Simpson and Joe 1993; Smith et al. 1995)
have begun to examine the relationships between the processes and
stages of change (Prochaska et al. 1992) and dropout. Studies have
tested the hypothesis that individuals' stages of change relate to their
retention in treatment; thus far, only modest support has been found
for this hypothesis.
Estimates of dropout from psychotherapy have ranged from
approximately 30 percent to 60 percent (Wierzbicki and Pekarik
1993). In their meta-analysis, Wierzbicki and Pekarik found the
mean dropout rate of 125 studies to be approximately 47 percent.
Dropout from drug and alcohol treatment is common and retention
rates are extremely variable. Carroll and associates (1994) reported
that only 49/121 (40 percent) of subjects in their study completed
treatment for cocaine dependence. In a study of inpatient alcoholics,
Carver and Dunham (1991) reported that only 71/141 (50 percent)
of subjects completed treatment. Simpson and Joe (1993) studied
dropout patterns in methadone maintenance clinics participating in
the Drug Abuse Treatment for AIDS-Risks Reduction (DATAR)
project funded by the National Institute on Drug Abuse (NIDA).
These authors found that 12 percent of methadone maintenance
patients terminated within 30 days, 24 percent within 60 days, and 35
percent within 90 days (N = 311). Sterling and colleagues (1994)
found that only 43/194 (22 percent) of individuals successfully
completed treatment for crack cocaine dependence.
No single variable has uniformly been associated with dropout from
drug or alcohol treatment. For example, in one study (McCallum et
al. 1992), severity of psychiatric symptoms predicted dropout, while
in two other studies (Ravndal and Vaglum 1994; Sterling et al. 1994),
no such relationship was found. Similarly, in one study (Carver and
Dunham 1991) renewed drinking was predictive of dropout, while in
another study (Ravndal and Vaglum 1994), renewed substance use was
not predictive of dropout. Two studies (Carroll et al. 1994; Simpson
and Joe 1993) reported that being married was positively correlated
with completing treatment. No such relationship was reported in the
other studies reviewed above.
An interesting finding, relevant to cognitive therapy, was reported in
two of the above-mentioned studies. Carver and Dunham (1991) and
209
Simpson and Joe (1993) found that patients' expectations for success
were related to reduced drug use and completion of treatment.
Expectations of success involve thoughts and beliefs about the
potential effectiveness of treatment. This finding is consistent with
the cognitive conceptualizations of substance abuse and dropout
described in the following sections.
THE COGNITIVE THERAPY OF SUBSTANCE ABUSE: A BRIEF
REVIEW
The authors’ basic model of substance abuse (Beck et al. 1993; Liese
1993, 1994a, 1994b; Liese and Chiauzzi 1995; Liese and Franz, in
press; Wright et al. 1992) is presented in figure 1. The model assumes
that certain activating stimuli (e.g., anxiety, interpersonal conflicts)
trigger basic drug-related beliefs and automatic thoughts about
substance use (e.g., "Drinking/smoking relaxes me!"). These beliefs
and thoughts, in turn, heighten individuals' urges and cravings to use
drugs. But not all urges and cravings lead individuals to drug use.
Instead, individuals who have facilitative beliefs about drugs (e.g., "Just
one won't hurt me") are likely to use drugs. In the presence of urges,
cravings, and facilitative beliefs, many individuals focus on actions
that prepare them for continued use and relapse, though some rare
individuals are able, at this critical point, to "just say no."
COGNITIVE CONCEPTUALIZATION OF MISSED SESSIONS AND
DROPOUT
The model for conceptualizing missed sessions and dropout is
presented in figure 2. This model is based on extensive discussions
with cognitive therapists and their drug-dependent patients. First,
therapists were asked to speculate about their patients' reasons for
missing sessions and dropping out. After formulating a tentative
model based on therapist responses, patients were asked: "What
circumstances and thoughts would
210
211
212
lead you to miss sessions or drop out of therapy?" Initially, many
patients denied any risk of dropout, exclaiming: "This is my last
chance for recovery. I won't drop out!" These individuals would then
be ask to respond hypothetically: "Let’s assume that you won't miss
sessions or drop out. But if it were to happen, what circumstances or
thoughts would be involved?" Patients also were asked to reflect on
the circumstances and thoughts associated with past missed sessions
and dropout. The model presented in figure 2 is based on answers to
these queries.
According to the authors’ conceptualization of missed sessions and
dropout, certain circumstances (e.g., continued alcohol or drug use)
place people at high risk for missed therapy sessions and dropout.
These circumstances activate certain beliefs about therapy or the
therapist (e.g., "Therapy won't help me," or "My therapist doesn't
understand me.") that are manifested as automatic thoughts (e.g.,
"Why bother?" or "What a jerk!"). These beliefs and thoughts lead
to emotions and behaviors associated with dropout.
The thoughts, feelings, and behaviors associated with missed sessions
and dropout tend to be self-reinforcing (i.e., they function in a cyclic
fashion; see figure 2). Certain emotions (e.g., despair, anger, anxiety,
guilt) and behaviors (e.g., drug use, missed sessions) function as
circumstances that increase the likelihood of future missed
appointments and dropout. Beckham (1992), for example, found
that missed sessions early in therapy were highly predictive of later
dropout. In the typical course of outpatient treatment for drug
dependence, individuals may become skeptical, believing that
"treatment isn't working" (especially in response to strong urges,
craving, or lapses). This belief may lead to missed sessions. Missed
sessions may lead to increased emotions of apathy, discouragement,
or guilt. These emotions may lead to additional missed sessions until
eventually this vicious cycle ends in dropout. In the following
paragraphs the authors’ conceptualization of missed sessions and
dropout is described in more detail, including the associated
circumstances, beliefs, automatic thoughts, emotions, and behaviors
associated with missing sessions and dropping out.
Circumstances Related to Missed Sessions and Dropout
Many circumstances potentially relate to missed sessions and dropout.
These circumstances include (but are not limited to) continued alcohol
or drug use, extended periods of abstinence, legal problems, medical
problems, psychological problems, family/relationship problems,
logistical problems, and therapeutic relationship problems. It is
213
important to note that these circumstances do not necessarily result
in missed sessions or dropout. Instead, they may activate beliefs or
thoughts that in turn result in missed sessions and dropout. Some
individuals drop out of therapy when they have lapses or relapse,
while others continue to attend therapy sessions when they are using
drugs or alcohol. Some individuals drop out of treatment when they
have legal, psychological, medical, or relationship problems, while
others drop out of treatment when they resolve these problems
(especially if they have entered treatment to avoid the negative
consequences of using, such as loss of children).
Continued Alcohol or Drug Use. Unfortunately, relapse is prevalent
among individuals attempting to abstain from alcohol and drugs (Hunt
et al. 1971; Marlatt and Gordon 1985, 1989). Lapses and relapses
may trigger distress, discouragement, helplessness, and hopelessness in
patients that, in turn, may lead to dropout. In addition to distress,
continued drug use may result in other problems in patients' lives,
which may further contribute to missed sessions and dropout. For
example, drug use can cause legal problems, medical problems,
psychological problems, family problems, logistical problems, and
problems in the therapeutic alliance. These circumstances (listed in
figure 2) are all discussed in this section.
Extended Periods of Abstinence. Just as there are individuals who
have slips, lapses, and relapses, there are others who succeed at being
abstinent from drugs and alcohol. These individuals, despite their
abstinence, are likely to have residual skill deficits. For example, they
may lack effective communication skills or mood-management
strategies that facilitate abstinence. If these individuals do not
perceive therapy as offering relevant skill development, or if they
perceive themselves as not needing to develop skills, they are likely
to miss sessions and drop out of treatment.
Abstinent individuals with substantial family or personal
responsibilities are at even higher risk for dropout. For example,
consider Gina, the young mother described above. At present Gina is
struggling to manage multiple life demands. She is likely to view time,
rather than therapy, as being her most precious resource. While
abstaining from drugs and alcohol, she is likely to view addiction
treatment as taking time away from her baby rather than being
beneficial to her continued abstinence.
Legal Problems. Drug-dependent individuals are at heightened risk
for legal problems. Many psychoactive drugs (e.g., cocaine, heroin,
214
hallucinogens) are illegal; the purchase, sale, and possession of these
drugs constitutes a punishable crime. Likewise, the use of legal drugs,
like alcohol, may also be associated with illegal behaviors (such as
driving under the influence). Psychoactive drugs are also expensive
and some individuals resort to illegal activities (e.g., robbery, theft,
prostitution) to acquire them. Even nicotine dependence can lead to
shoplifting if the smoker does not have the financial means to
purchase cigarettes. Chronic drug use may also lead to significant
impairment in judgment, resulting in uncharacteristic illegal behaviors.
While many drug-dependent individuals do not engage in illegal
activities themselves, they may associate with others who do. Mary
(described above), for example, has never engaged in significant illegal
behaviors. However, when she is actively using cocaine she is drawn
to one particularly violent, aggressive, antisocial, drug dependent man
who deals drugs.
As drug-dependent individuals become increasingly involved in illegal
activities, they are at heightened risk for dropout for several reasons.
First, they may be ashamed of their behaviors. Second, they may be
afraid of the potential legal consequences of discussing their behaviors
with others (e.g., therapists). And third, they may be incarcerated for
their illegal behaviors, making treatment inaccessible. It is important
to acknowledge that some individuals are mandated to enter treatment
as a result of their legal problems. These individuals are particularly
prone to drop out when their legal problems are resolved (for
example, when criminal charges against them are dismissed).
Medical Problems. It is well known that psychoactive drugs are
associated with numerous medical problems. For example, cigarettes
are associated with almost half a million deaths per year (from heart
disease, pulmonary disease, a variety of cancers, and numerous other
medical problems). Alcohol is associated with almost 100,000 deaths
per year (from liver disease, gastrointestinal disorders, vascular
diseases, malnutrition, and trauma). Cocaine has been linked to heart
attacks, strokes, hypertension, and trauma. Marijuana smoking is
associated with pulmonary disease, depression, and amotivational
syndrome. Medical problems resulting from drug abuse often result in
the initiation of drug treatment. However, when individuals become
seriously ill or hospitalized they are less likely to continue treatment
and more likely to drop out.
Psychological Problems. Just as psychoactive substances lead to
medical problems, they may also lead to psychological problems.
Many psychoactive drugs act as central nervous system stimulants and
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depressants and their chronic abuse may lead to serious psychological
problems which may, in turn, lead to missed sessions and dropout.
For example, Mary suffers from recurrent depressive episodes,
exacerbated by her cocaine use. One of the most salient symptoms of
Mary's depression is hopelessness. Any indications that Mary is
"failing" in therapy might activate hopeless thoughts (e.g., "It's
useless to attend therapy; I'll never improve."). Hopelessness may
eventually lead to complete withdrawal from treatment.
Family/Relationship Problems. It is well known that chronic
substance use has a negative impact on families and interpersonal
relationships. These problems may lead to missed sessions or
dropout. Gina, for example, currently has almost no social or family
support. At one time Gina's mother would help her with money and
child care so Gina could work and attend therapy. However, Gina's
mother decided to stop providing assistance to Gina after discovering
that Gina was using her money and free time to use drugs. At the
urging of her Al-Anon group, Gina's mother elected to take a tough
love stance with Gina by withdrawing all support from her. The
inadvertent effect was the escalation of missed sessions and eventual
dropout.
Similar to legal and medical problems, family and relationship
problems may also result in the initiation of treatment. Many
individuals enter treatment to avoid the negative consequences of
their drug use (e.g., loss of a marriage or children). These individuals
are particularly vulnerable to dropout when they believe that their
family problems are resolved.
Logistical Problems. Many drug-dependent individuals are vulnerable
to logistical problems, including difficulties with finances,
transportation, and child care. It is common for addicted individuals
to lose their drivers' licenses, jobs, and even homes as a result of their
drug use. At one time, Bob was a financially successful attorney.
However, as a result of his drug use he lost his wife, job, savings, car,
and home. Like Mary and Gina, Bob did not have enough money to
pay the taxi fare to attend treatment. Given his narcissistic
personality, he attributed these problems to events outside of himself
(e.g., getting "ripped off" by others who were envious of him). He
dropped out after concluding that he had "more important things to
do than go to therapy."
Therapeutic Relationship Problems. Given the numerous problems
encountered by drug-dependent patients, the development and
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maintenance of collaborative therapeutic relationships may be
difficult. Patients are likely to feel ashamed, depressed, or angry at
themselves for their problems. They may fear that therapists will
judge them or be upset with them. Therapists may, indeed, have
strong negative feelings towards their drug-dependent patients and
convey these to patients. When this occurs, therapy becomes
aversive and patients are likely to drop out.
Most treatment models strongly encourage, require, or demand that
patients be fully abstinent from drugs and alcohol during and after
treatment. These models may convey the messages: "If you use
drugs or alcohol we can't help you," or "If you use drugs or alcohol
you have failed and disappointed us." Such messages may intimidate,
discourage, frustrate, and anger drug-dependent individuals, who may
drop out of treatment following any drug use. In each of the three
case examples described above, therapists viewed drug or alcohol use
as catastrophic and intolerable. While they did not overtly express
anger or frustration, they conveyed disappointment and disapproval
in subtle ways.
Unfortunately, inexperienced cognitive therapists are likely to
underestimate the difficulty and importance of developing
collaborative relationships with their drug-dependent patients. In
response to certain patient behaviors (e.g., missed appointments,
relapse, dropout), therapists are likely to experience emotional
distress, including feelings of frustration, irritation, anger, boredom,
and despair. Therapists' distress, of course, can be attributed to their
negative beliefs. Among the therapist beliefs that lead to distress are
the following (Liese and Franz, in press):
•
•
•
•
•
•
•
•
•
This patient is a typical drug addict!
After detox this patient will just relapse again!
This patient thinks I'm stupid!
This feels like a waste of my time!
All addicts are the same!
Lapses and relapses are catastrophic!
Missed sessions are awful/terrible/intolerable!
This patient doesn't want to change!
I'm working harder than this patient!
Hence, a vicious cycle may emerge wherein both therapist and patient
reinforce each other’s worst fears. When patients sense their
therapists' distress they, of course, become vulnerable to dropout.
217
To illustrate the cyclic nature of missed sessions and dropout, consider
the example of Mary, presented earlier. At the beginning of her third
session with Dr. A, Mary felt discouraged about her recent drug use.
During the session she became visibly distressed. Instead of attending
to her despair and responding empathetically, Dr. A focused
exclusively on Mary's recent drug use. By the end of the session Mary
felt ashamed, confused, and angry at herself for "being so weak." As
Mary's fourth session approached she thought, "I never succeed at
anything I do, so why bother with therapy? Besides I don't like my
therapist." She canceled her fourth and fifth sessions, which
heightened her belief that therapy would not help her. Eventually she
made another therapy appointment, but in this session Dr. A was very
confrontive about Mary's missed sessions and her commitment to
therapy. Mary again felt extreme despair. Her corresponding
thoughts were, "It's hopeless. I can't quit using drugs. Talking about
my problems only makes me feel worse. If I return to therapy I'll
only disappoint Dr. A." When it was time to return for her next
scheduled appointment, Mary reflected on the last visit and decided,
once and for all, "I'm just not getting anything out of therapy." She
never again returned for therapy and her drug abuse worsened.
Beliefs Activated
As the model was being developed, the authors began to search for the
idiosyncratic beliefs leading to dropout, for example: "Therapy isn't
likely to help me," "My therapist doesn't understand me," "I don't
want to quit using drugs yet," and "It's uncomfortable to talk about my
problems." It was assumed that knowledge of these beliefs would
facilitate increased empathy for drug-dependent patients and lead to
specific techniques for retaining patients in treatment. With the help
of therapists and patients, the search generated hundreds of beliefs
associated with missed sessions and dropout. From these, a list of 50
beliefs was distilled (see appendix). In the following paragraphs, the
three case examples are used to illustrate these beliefs.
Mary, discussed earlier, began crying in her third therapy session.
When the therapist did not offer tissues or act in a conciliatory
manner, she probably began to think: "I can't quit using drugs" (item
7); "I'm helpless, so what's the point of trying to quit?" (item 12),
and; "I never succeed at anything I set out to do" (item 22). Of
course these beliefs, consistent with her depression, put her at high
risk for missing future sessions and dropout. Unfortunately, these
beliefs also put her at high risk for continued drug use. As Mary
continued to use drugs while in therapy, she developed such additional
218
beliefs as: "I really, really can't quit using drugs" (item 7); "I don't
deserve help since I'm still using drugs" (item 25), and; "I'll just get
upset if I go to a therapy session" (item 38).
Bob, who was narcissistic, was likely to hold the following beliefs:
"My therapist doesn't understand me" (item 11), "I don't really like
my therapist" (item 23), and "I have more important things to do
than go to therapy" (item 39). As a result of these beliefs, he would
feel annoyed at his therapist and see little value in attending sessions.
Gina, an educationally and economically disadvantaged young mother,
was likely to react to her therapist's lecture with such beliefs as "I'm
not smart enough to benefit from this therapy" (item 8), "I don't like
this type of therapy" (item 24), and "I can't make the necessary
arrangements so I won't go to therapy" (item 41). Naturally, these
beliefs led her to avoid therapy until she eventually dropped out.
Automatic Thoughts
As previously mentioned, automatic thoughts are brief, abbreviated
versions of basic beliefs. Automatic thoughts exert powerful effects
on emotions and behaviors, yet they often manifest themselves in
ways that are undetectable to the person experiencing them.
Examples of automatic thoughts leading to missed sessions and
dropout include, "Not today," "It's hopeless," and "He's a jerk!"
(referring to the therapist).
Emotions and Behaviors Related to Missed Sessions and Dropout
As drug-dependent individuals encounter the above-mentioned
circumstances, beliefs, and thoughts, they are likely to experience
significant negative emotions (e.g., sadness, anxiety, anger,
frustration, disappointment, and despair). Furthermore, they are
likely to miss and cancel appointments.
As mentioned previously, these feelings and behaviors are likely to
function in a cyclic fashion. That is, they are likely to become the
circumstances that further perpetuate beliefs leading to dropout. To
illustrate, again consider Gina. When Gina received her 35-minute
lecture from Dr. C, she thought "I don't really like my therapist."
This thought contributed to several missed sessions. When she missed
a session, Dr. C would demonstrate his frustration by lecturing Gina
about the importance of attending sessions. Thus, Gina's negative
beliefs about her therapist were confirmed and the pattern of missed
219
sessions escalated. These missed sessions, in turn, led to therapeutic
relationship problems, which finally resulted in dropout.
SKILLS FOR KEEPING DRUG-DEPENDENT INDIVIDUALS IN
TREATMENT
The final sections of this chapter present fundamental skills for
keeping drug-dependent individuals in treatment. These skills
correspond with the five components of cognitive therapy described
by Liese (1994b; Liese and Franz, in press): (1) collaboration, (2)
case conceptualization, (3) structure, (4) socialization, and (5)
cognitive-behavioral techniques.
Establish and Maintain Collaborative Therapeutic Relationships With
Drug-Dependent Patients
Certainly the most important strategy for reducing dropout is to
develop and maintain genuine, warm, caring, empathetic relationships
with drug- dependent patients. While most experienced therapists
possess basic collaboration skills, many seem to forget these skills
when working with drug-dependent patients. It is assumed that
therapists' distress is a result of their negative beliefs about their
effectiveness with drug-dependent individuals (e.g., "It's hopeless;
they'll never change" and "My patients' success is a function of my
competence"). Many therapists are unaware of their own negative
reactions to drug-dependent patients; the process of collaboration can
begin only when they acknowledge their negative feelings towards
such patients.
It is essential for therapists to recognize that their negative emotions
magnify patients' problems and increase their likelihood of dropout.
Patients often recognize their therapists' distress and respond by
withdrawing from therapists (i.e., by dropping out). Patient dropout
further exacerbates therapists' distress. In fact, Magnavita (1994)
described dropouts as potentially demoralizing to therapists.
Therapists are strongly encouraged to carefully monitor their own
thoughts and feelings throughout the treatment process.
The authors of this chapter believe that abstinence is the most
appropriate goal for drug- and alcohol-dependent individuals.
Nonetheless, cognitive therapists are encouraged to "meet patients
where they're at" in their readiness to change. This can be
accomplished by helping patients learn important lessons from each
220
episode of drug use. This attitude is consistent with harm-reduction
philosophies advocated by Marlatt and colleagues (Marlatt and Tapert
1993; Marlatt et al. 1993). Simply stated, therapists are encouraged
to accept the fact that their addicted patients may occasionally (or
even frequently) use drugs. Therapists who attempt to persuade and
cajole patients to be abstinent are likely to be ineffective. Drs. A, B,
and C all felt an urgency to stop their patients from using drugs.
Their patients, recognizing this urgency, felt uncomfortable with
these therapists and eventually withdrew from treatment. One might
assume that any of these patients would have continued treatment if
relationships with their therapists had been better.
Develop an Accurate Case Conceptualization for Each DrugDependent Patient, Paying Careful Attention to Factors Associated
With Dropout
Cognitive therapists learning to treat drug-dependent patients often
underestimate the importance of the case conceptualization. As a
result, they fail to anticipate and adequately address dropout. The
models of substance abuse and dropout (figures 1 and 2) were reviewed
earlier in this chapter because the authors believe they will be helpful
in conceptualizing dropout.
For example, with an accurate case conceptualization, Dr. A would
have realized that Mary's drug use was linked to her depressed feelings
and underlying helpless and hopeless beliefs about herself. Rather
than focusing on her most recent binge, which resulted in her
heightened despair, Dr. A would have recognized and addressed her
despair.
With an accurate case conceptualization, Dr. B would have recognized
that Bob's drug use was linked to his frantic (narcissistic) efforts to
view himself as powerful and superior to others. Rather than focusing
on Bob's maladaptive thoughts about cocaine, Dr. B would have
focused on Bob's belief that others do not understand him.
Without an accurate case conceptualization, Dr. C overestimated
Gina's interest in, and ability to comprehend, the cognitive model of
substance abuse. Rather than lecturing Gina, Dr. C should have
explored how overwhelmed she generally feels and how she would
manage to attend therapy given the many demands already on her.
The list of beliefs leading to missed sessions and dropout in the
appendix is particularly helpful for conceptualizing patients’ beliefs
221
about dropout. Therapists are encouraged to memorize these beliefs
and use open-ended questions to elicit beliefs that potentially lead to
dropout. For example, therapists are encouraged to ask: "When you
don't feel like coming to therapy, what thoughts go through your
mind?" and "How do you respond to inevitable thoughts of not
continuing therapy?"
Use the Structure of Cognitive Therapy To Anticipate and Address
Potential Dropout
Therapists are encouraged to utilize the structure of cognitive therapy
to detect and address potential dropout. The structure of a typical
session includes: (1) agenda setting, (2) mood check, (3) bridge from
the last session, (4) discussion of current agenda items, (5) feedback,
and (6) homework. Each step may be used in unique and important
ways to reduce the likelihood of dropout, as discussed in the following
paragraphs.
Cognitive therapy sessions begin with agenda setting wherein
therapists ask, "What would you like to work on today?" In response
to this question, patients often respond, "I don't know," or
"Whatever you want to work on." Another common response is,
"Everything's going great! I can't think of anything to work on."
Such responses might reflect problems with motivation or
commitment to therapy. Thus, it is important for therapists to
seriously address such responses when they occur. The best initial
response to the absence of an agenda item is, "That's okay. Just take
some time and think about what you'd like to work on." When
patients persist in having no agenda items, it might be appropriate to
say, "It's interesting that you can't think of anything to work on.
What are your current thoughts about being in therapy?" As the
patient responds to this question, it is particularly important to be
attentive to beliefs potentially associated with dropout.
The mood check is the next step in a typical cognitive therapy
session. Since mood disturbances reflect negative feelings and beliefs,
the mood check provides an opportunity to elicit beliefs and feelings
related to dropout. Thus, it may be an excellent time to detect
skepticism, pessimism, or hopelessness about therapy. In addition to
asking, "How is your mood today?" therapists are encouraged to
specifically ask, "How do you feel about being here today?"
The bridge provides another excellent opportunity to evaluate
potential for dropout. During the bridge the therapist asks the
222
patient, "What do you remember from our last session?" or "What did
we work on in our last session?" It is during the bridge that therapists
also ask patients about any drug use, urges, or cravings since the last
visit, as well as upcoming situations potentially leading to drug use.
Patients' responses to these questions might reveal circumstances
potentially leading to dropout. For example, patients who cannot
recall any significant benefits from previous visits might not view
therapy as beneficial. Patients who have been using drugs since the
last visit, of course, might be vulnerable to dropout. Minimization or
denial of urges and cravings might reflect patients' fears of being
honest with their therapists.
Before discussing agenda items, therapists are encouraged to prioritize
these items with patients. While it might seem appropriate to focus
exclusively on drug use, neglecting other matters important to the
patient might convey the message, "I don't care about you; I only
care about stopping you from using drugs." Such messages increase
the likelihood of dropout. During the discussion of agenda items, it is
essential for therapists to remain focused. Focusing involves listening
carefully and remaining attentive to current agenda items until some
resolution or closure is achieved. In contrast, some therapists enable
patients to drift from topic to topic, leaving both parties feeling
unfulfilled. When this occurs, the patient is vulnerable to thinking,
"Therapy is not likely to help me," which, of course, may lead to
dropout.
Another structural aspect of cognitive therapy is feedback, wherein
therapists ask patients to discuss their reactions to therapy. Typical
questions for eliciting feedback are, "What are your thoughts and
beliefs about therapy?" and "What are you getting out of therapy?"
By regularly asking for feedback, therapists may directly assess
patients' potential for dropout. The list of beliefs in the appendix is
likely to be helpful in this process. Each item can be reworded as a
question, for example:
"How do you think therapy will help you with your alcohol/drug
problems?" (item 1)
"How do you feel about my monitoring your drug use?" (item 3)
"Since you still have strong urges and cravings, how do you think
therapy is helping you?" (item 9)
"Since you've been abstinent for 6 months, what's motivating you to
continue therapy?" (item 21)
223
After asking these questions, it is important for therapists to listen
carefully to patients' responses. Specifically, if patients' answers are
vague or negative, it is essential to ask for elaboration. In the case of
Gina, Dr. C asked whether she understood his lecture. When she
answered "I guess so," he failed to recognize the tentativeness of her
response. If he had responded to her skepticism, he might have
anticipated and addressed the beliefs leading to her eventual dropout.
The final component of cognitive therapy sessions is homework.
Homework, in many ways, is a direct measure of individuals' readiness
to make changes in their lives. Both the assigning and reviewing of
homework may facilitate retention in treatment. For example, by
assigning appropriate homework consistent with patients' readiness to
change, patients are likely to remain engaged in the treatment process
and be less likely to drop out. In contrast, if homework assigned is
inappropriate (e.g., too difficult or irrelevant to the patient’s main
problems), the patient will begin to develop beliefs leading to dropout.
In reviewing homework, the therapist can infer, to some degree,
patients' commitment to the treatment process. For example,
patients who do not do homework might be conveying (indirectly)
thoughts of helplessness or hopelessness. It is important to address
these matters.
Socialize Patients in a Timely, Effective Manner
Socialization is an important and popular feature of cognitive
therapy. Socialization is synonymous with the term "education," and
it involves teaching patients to better understand themselves and their
drug use. Socializing may occur in several different content domains.
For example, therapists may teach patients about the cognitive model
of substance abuse, about cognitive distortions, or about the medical
consequences of drug abuse. Two ingredients of socialization appear
to render it more or less effective: appropriateness and timing of the
information presented.
Appropriateness is defined as the degree to which the information
presented is relevant to the patient's interests and needs. Timing is
defined as the delivery of the information at the appropriate
moment. Appropriateness and timing require that the therapist listen
carefully and empathetically to the patient. The effective delivery of
information requires an accurate case conceptualization, including an
understanding of the patient's readiness to acknowledge problems and
make changes.
224
Two examples of inappropriate, poorly timed socialization attempts
are apparent in the examples of Drs. B and C with Bob and Gina.
Neither patient was particularly interested in their therapists' lectures,
and neither seemed ready to integrate the information provided by
their therapists. At times therapists believe that their patients need
or want information. However, to test this assumption, therapists are
encouraged to first ask questions to evaluate their patients' interests
and knowledge levels. For example, rather than telling Bob how
therapy works (i.e., by "eliminating thoughts and beliefs that lead to
drug use"), Dr. B might have asked him, "Have you ever wondered
how you could give up cocaine when you enjoy it so much?"
Use Cognitive and Behavioral Techniques Appropriately and
Sparingly, and Base the Selection of Techniques on Accurate
Case Conceptualizations
When cognitive therapy was originally introduced as a treatment for
the acute psychiatric problems of depression and anxiety, emphasis
was on structure, socialization, and techniques. This emphasis was
appropriate for patients with these acute disorders. However, the
simplicity and effectiveness of cognitive and behavioral techniques
with these disorders led to their overemphasis and overuse. In
response, Beck (1991) stated: "One of the misconceptions of
cognitive therapy is the notion that it can be defined simply in terms
of a set of cognitive techniques" (p. 195).
There are many potential techniques in the cognitive therapy of
substance abuse. For example, the advantages-disadvantages analysis
is useful for evaluating the negative and positive consequences of
patients' drug use. The daily thought record is useful for helping
patients examine and evaluate their beliefs leading to drug use. And
cue cards provide reminders of reasons for abstaining from drugs and
alcohol. (For detailed discussions of these and other techniques, see
Beck et al. 1993.)
For cognitive-behavioral interventions to be effective, they must be
timed well and they must be delivered appropriately. When either of
these criteria is unmet, the likelihood of dropout is increased. Poor
timing is characterized by delivery of a technique at the wrong time,
while poor delivery is defined as the ineffective execution of a
technique.
225
Similar to the process of socialization discussed earlier, there are
appropriate and inappropriate times to deliver techniques. In the
examples above, Drs. A, B, and C all delivered interventions at
inappropriate times. Mary, Bob, and Gina were all ill-prepared for
their therapists to tell them how to fix their problems. Instead, each
patient probably would have responded best to empathy, support,
validation, and encouragement. Regarding the delivery of cognitivebehavioral techniques, some styles are more collaborative than others.
Debating and lecturing, for example, tend to be less effective than
guided discovery (i.e., therapist-guided exploration of problems and
solutions).
SUMMARY
Cognitive therapists who treat drug-dependent patients are likely to
lose at least 50 percent of their patients to dropout. This chapter has
presented a cognitive model for conceptualizing missed sessions and
dropout, along with strategies for reducing the likelihood of missed
sessions and dropout. The following should serve to highlight these
strategies.
1. Therapists are encouraged to offer warm, empathetic,
collaborative relationships in which drug-dependent patients can
feel accepted, understood, and validated.
2. Therapists are encouraged to develop comprehensive, accurate
case conceptualizations, with attention paid to the potential for
missed sessions and dropout. Case conceptualizations should
ultimately guide cognitive and behavioral techniques.
3. Therapists are encouraged to structure sessions and elicit feedback
regarding their patient's thoughts and beliefs about therapy and
the therapist. This feedback is facilitated by such questions as,
"What do you like most about therapy?" "What do you like
least?" "What has changed in your life as a result of therapy?"
"How do you view our relationship?"
4. Therapists are encouraged to socialize patients in a timely,
appropriate manner.
5. Similar to the process of socialization, therapists are encouraged
to use cognitive and behavioral techniques in a timely,
appropriate manner.
226
It is unrealistic to think that the problems of missed sessions and
dropout from drug treatment will ever be fully resolved. Nonetheless,
the authors believe that the conceptual models and fundamental
strategies presented in this chapter represent a significant step in
addressing these problems.
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ACKNOWLEDGMENTS
The authors would like to express their gratitude to Dayanand
Shepherd, Kim A. Seaton, M.A., and Susan Paolo, Ph.D., for their
invaluable support and comments on early drafts of this paper.
AUTHORS
Bruce S. Liese, Ph.D.
Associate Professor
Kansas University Medical Center
3901 Rainbow Boulevard
Kansas City, KS 66160
Aaron T. Beck, M.D.
President
Beck Institute for Cognitive Therapy and Research
GSB Building
Suite 700
1 Belmont Avenue
Bala Cynwyd, PA 19004
230
APPENDIX: Beliefs leading to missed sessions and
dropout.
1. "Therapy won't help me with my alcohol/drug problems."
2. "My therapist can't help me because he or she has never been
addicted."
3. "I don't want some therapist breathing down my neck."
4. "Talking about alcohol/drugs just makes me want to use more."
5. "I'm better off just trying to forget my alcohol/drug problem."
6. "If I continue therapy I'll just disappoint the therapist."
7. "I can't quit using alcohol/drugs."
8. "I'm not smart enough to benefit from this therapy."
9. "I keep getting urges and cravings so therapy isn't helping me."
10. "Alcohol/drugs are a big part of my life. I'm not ready to give
them up."
11. "My therapist doesn't understand me."
12. "I'm helpless, so what's the point in trying to quit?"
13. "A psychotherapist can't help me."
14. "Psychotherapists are for crazy people."
15. "No one can tell me what to do."
16. "I don't see how talking about my problem can help me."
17. "Alcohol/drugs are my only source of enjoyment and relaxation."
18. "My problem is physical, not mental, so I don't need a
psychotherapist."
19. "The therapist is never there when I really need him or her."
20. "I should be strong enough to do this myself."
21. "I haven't used in some time so I don't have a problem anymore."
22. "I never succeed at anything I set out to do."
23. "I don't really like my therapist."
24. "I don't like this type of therapy."
25. "I don't deserve help since I'm still using alcohol/drugs."
26. "Talking about my problems only makes me feel bad about them."
27. "I'm too busy to go to therapy."
28. "I'll just relapse anyway so it's stupid to go to therapy."
29. "I'm not getting anything out of therapy."
30. "I'll never stop using alcohol/drugs."
31. "I'm not going to therapy because I used recently."
32. "I know more about addictions than my therapist."
33. "I can't stand it when my therapist confronts me."
34. "I just don't feel like talking."
35. "It won't hurt to miss a session here or there."
36. "I don't know what to talk about so I won't go to therapy."
37. "I can't go to my therapy session because I haven't done the
homework."
231
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
"I'll just get upset if I go to a psychotherapy session."
"I have more important things to do than go to therapy."
"I'm too upset to talk right now."
"I can't make the necessary arrangements so I won't go to
therapy."
"I need to be in the right mood to go for therapy."
"Only people who are screwed up go to therapy."
"My therapist never believes what I say."
"I don't like it when my therapist says my head is messed up."
"I have a right to do what I want with my body."
"No other treatment has helped so this won't."
"I don't want to have to explain myself to anyone."
"If I tell my therapist what's really going on, he or she will
abandon me/criticize me."
"I just want to forget my problems."
232
Establishing a Therapeutic Alliance
With Substance Abusers
Lester Luborsky, Jacques P. Barber, Lynne Siqueland, A.
Thomas McLellan, and George Woody
To understand a research problem, it helps to first look back at its
origins. For each of the three topics in this chapter, the authors first
look back, then look ahead to see how to use what is known about (1)
the concept of the alliance, (2) its translation into measures for
substance abuse research, and (3) its use in improving psychotherapy
outcomes in drug abuse treatment.
THE CONCEPT OF THE THERAPEUTIC ALLIANCE
Where else should the alliance concept have started but with Freud
(1912)? Freud took for granted the need to first establish rapport as
part of developing an alliance with the patient, an essential ingredient
of effective treatment. Much later, Bordin (1976, 1980) elaborated a
theoretical framework that also set the stage for the later
development of measures of the alliance.
The influences of both Freud's and Bordin's concepts on the
development of measures of the alliance are apparent. Bordin
described three components in the alliance: goals, tasks, and bonds.
In a well-functioning treatment relationship, the patient and therapist
come to an agreement about the goals the patient wishes to achieve in
the treatment. They also come to accept certain therapeutic tasks as
potentially helpful for achieving those goals. The bonds that form
between patient and therapist in the course of working on the tasks
include the positive personal attachments that stimulate trust and
confidence.
MEASURES OF THE ALLIANCE AND THEIR RESULTS IN
SUBSTANCE ABUSE RESEARCH
In 1974, Bordin arranged a program on concepts of the alliance for
the 1975 Society for Psychotherapy Research annual meeting and
asked Luborsky to participate. To get ready for that meeting,
Luborsky looked back over Bordin's concepts, examined transcripts of
psychotherapy sessions, took note of the inferences about the
233
alliance, and started to develop operational alliance measures,
including two transcript-of-sessions methods: the Helping Alliance
Counting Signs method (HAcs) (Luborsky 1976) and a session-based
rating method, the Helping Alliance Rating Method (HAr) (Morgan et
al. 1982). About 1977, Woody, McLellan, and Luborsky began a
study of opiate-dependent patients (Woody et al. 1983) involving the
use of another alliance measure, the Helping Alliance questionnaire
(HAq) (Luborsky 1984; Luborsky et al. 1985; see also a review of
research with that questionnaire in Luborsky et al., unpublished). It is
therefore fitting that the conference on the therapeutic alliance was
sponsored by the National Institute on Drug Abuse (NIDA), because
Woody and colleagues’(1983) NIDA-supported study was the first use
of a questionnaire called an alliance measure as a predictor of the
outcome of psychotherapy.
This review is restricted to measures that are called alliance measures.
There were earlier studies, based on a variety of more general
measures of relationship patterns (mostly called relationship
measures), especially Barrett-Lennard's Relationship Inventory
(Gurman 1977). The authors’ shift in label to "alliance," however,
may have been a substantive one reflecting more than just a change in
the name, but also a greater focus on a specific active ingredient of
the relationship, the alliance.
The remainder of this section describes the main substance abuse
studies that have used alliance measures, Woody and colleagues (1983)
and Luborsky and colleagues (1985). Their aim was to determine
whether psychotherapy added significantly to treatment as usual (drug
counseling) for opiate-dependent patients. Psychotherapy was found
to add to the patients’ benefits from treatment. For the combined
sample of four types of treatment—cognitive-behavioral (CB),
dynamic, supportive-expressive (SE), and drug counseling (DC)—the
alliance, as measured by the HAq, significantly predicted outcomes of
the psychotherapies (r = 0.65, p < 0.01). The Woody and associates
study (1983) played a big part in the drug abuse field by stimulating
what has become the popular use of alliance measures in psychosocial
treatment studies with many types of psychiatric patients.
Several subscales on the Addiction Severity Index (ASI) (McLellan et
al. 1980) (higher severity is associated with lower adherence)
correlated highly with the HAq, such as drug use (0.72, p < 0.01) and
psychological functioning (0.58, p < 0.01). These ASI scores were
taken at the 7-month outcome point, 1 month after the 6 months
234
allotted treatment time. The therapist form of the HAq gave similar
results.
Gerstley and colleagues (1989) offered a new analysis of the alliance
data collected by Woody and associates (1983), specifically
examining psychotherapy outcomes on patients with the diagnosis of
antisocial personality disorder. Gerstley and associates (1989) built up
the work of Woody and colleagues (1985), who compared four
diagnostic subgroups: opiate dependence alone (N = 16), opiate
dependence plus depression (N = 16), opiate dependence plus
depression plus antisocial personality disorder (N = 17), and opiate
dependence plus antisocial personality disorder (N = 13). Patients
with opiate dependence plus antisocial personality disorder improved
the least, showing change only on ratings of drug use. Patients with
opiate dependence alone or with opiate dependence plus depression
improved significantly and in many areas. Therefore, the general
finding was that antisocial personality disorder alone is a negative
predictor of psychotherapy outcome, but that co-occurring depression
appears to improve the patient's amenability to psychotherapy.
It is noteworthy that in Woody and associates’ (1983) study, 76
percent of the sample met research diagnostic criteria (RDC) for at
least one psychiatric disorder in addition to drug dependence.
Nineteen percent of the patients met RDC standards for antisocial
personality disorder, but 45 percent of the patients met the antisocial
personality disorder criteria when "Diagnostic and Statistical Manual
of Mental Disorders," 3rd ed. (DSM-III) criteria were used.
Gerstley and associates (1989), using the same data as Woody and
associates but with the HAq, examined patients’ capacity to form an
alliance with the therapist when the diagnosis met DSM-III antisocial
personality disorder criteria. Their new findings were that some
patients diagnosed with antisocial personality disorder were able to
form a positive relationship with their therapist, as measured by their
scores on the HAq-I, and that these scores correlated with
improvement in psychotherapy. The HAq therefore helped in
identifying which antisocial personality disorder patients would
benefit from psychotherapy.
In a study by Luborsky and associates (in press), two alliance measures
were compared with each other in the pilot phase of a large-scale
NIDA multisite collaborative psychotherapy outcome study for
cocaine disorder patients; the measures were the Penn Helping
Alliance questionnaire-II (HAq-II) (Luborsky et al., in press) and the
235
California Psychotherapy Alliance Scale (CALPAS) (Marmar et al.
1989). The patient sample was drawn from the four sites of the
NIDA collaborative study at hospitals in Nashua (NH), Philadelphia,
Pittsburgh, and Boston. The two alliance scales were filled out by
approximately 250 patients early and late in the course of 6 months
of psychosocial treatment for cocaine dependence.
Two findings emerged (Luborsky et al., in press) from the analysis of
the data: Internal consistency was high for the items of the HAq-II as
well as for those of the CALPAS scale, and was also evident in both
the patient and therapist forms for each measure. The HAq-II and
the CALPAS were moderately correlated with each other, with
correlations between the patient version of the two forms at sessions
2, 5, and 24 of 0.59, 0.64, and 0.75, respectively, and with similar
correlations of 0.78, 0.79, and 0.94 for the therapist version of the
two measures. (The predictions of outcome will be reported in a
future publication.)
APPLICATIONS OF PROCEDURES FOR IMPROVING THE ALLIANCE
AND THE OUTCOMES IN PSYCHOTHERAPY
The field is at an early stage in terms of studies of how to use the
knowledge of the alliance to improve the alliance for both addicted
patients and other patients. Although the field already has some
applied quantitative studies, it is worth relying also on what has been
learned clinically. These clinical studies are sampled below.
Clinical Procedures
Freud (1912) offered two specific recommendations to improve the
rapport between patient and therapist: do nothing to interfere with
the natural development of rapport, and listen with sympathetic
under-standing. Similarly, Rogers (1957) recommends showing
empathy and positive regard.
An extended set of recommendations was assembled for improving
the alliance (Luborsky 1984, 1993).
1.
2.
Convey support for the patient's wish to achieve the patient's
goals. This can be done by reviewing the patient's goals from
time to time to clarify them and to relate what is being done
in the therapy to meet these goals.
Offer understanding and acceptance of the patient.
236
3.
Develop a liking for the patient or for important aspects of
the patient.
4.
Help the patient who needs support to hold on to vital
defenses and activities that maintain the patient's level of
functioning.
5.
Convey a realistically hopeful attitude that the treatment
goals are likely to be achieved and that the therapist is trying
to help the patient achieve them.
6.
Recognize on appropriate occasions that the patient has made
some progress toward the goals.
7.
Find ways to encourage some patients to express themselves
on some occasions.
Clinical-Quantitative Procedures
The positive correlations of early alliance measures with treatment
outcome imply that strengthening the alliance should improve the
outcome of treatment. In fact, the current authors found a
correlation in the Penn psychotherapy sample of 43 patients between
the early sessions scores on the HAcs method (Luborsky et al. 1983)
and outcome measures: 0.31 (p < 0.05) with rated benefit and 0.36 (p
< 0.05) with residual gain. A meta-analysis of 24 studies by Horvath
and Symonds (1991) found an average effect size of 0.26 of alliance
scores with therapy outcome, although the mean correlation was
diminished by counting all nonsignificant correlations as zero. It has
also been reported that the state of the alliance is related to the
choice of a therapist (Alexander et al. 1993).
But many of those in the field are part of the here-and-now
generation of researchers who ask for clinical-quantitative
verification of the value of any clinical methods for improving the
alliance. Fortunately, the field has a few studies that deal with
improving the level of the alliance. Although none of these studies
involves patients with drug abuse problems, effects are likely to be
similar across different types of patients (Luborsky et al. 1991). A
sample of the recommendations from the applied studies follows.
Picking Successful Therapists. There is evidence that therapists
who have a good level of success with patients have patients who
237
develop a good alliance with them (Luborsky et al. 1985). This is a
promising finding and bears replication and analysis of the methods
used by these therapists in establishing an alliance.
Repairing Ruptures in the Alliance. Foreman and Marmar (1985),
followed by Gaston and colleagues (1989), were the first to assemble
examples of impairments in the alliance and suggest a method for
repairing them. Safran and associates (1990, 1994) have also set up
methods for showing that ruptures in the alliance can be identified and
that there are ways of healing them. The main way to improve the
alliance, as suggested by Foreman and Marmar (1985) and Safran and
associates, is to focus on the problems within the patient-therapist
relationship, rather than on problems in outside-of-treatment
relationships. The benefits of this kind of focus on the improvement
of the patient-therapist relationship have been shown by others as
well (Coady 1991).
Increasing Therapists’ Alliance-Facilitating Behaviors. A likely area
to search for evidence about factors influencing the development of
the alliance is within therapists' behaviors that facilitate the alliance.
One scale that may be useful to help focus this exploration is called
the Therapist Facilitating Behaviors Scale (Luborsky et al. 1988).
Scores on this scale have been found to correlate with the alliance
scores. For 20 patients in the Penn psychotherapy sample, there was
considerable association between the two types of measures; for
example, early helping alliance ratings correlated 0.85 (p < 0.001)
with early therapist's facilitating behaviors rating. It is natural with
such a high correlation to suspect that one of the factors influencing
formation of the helping alliance is the therapist's ability to facilitate
alliances.
Dealing With the Relationship Problems. Several studies that are not
specific to the therapeutic alliance may give suggestions about factors
related to developing and maintaining such an alliance. Kivligahn and
Schmidz (1992) showed that therapists who were more inclined to
deal with the therapeutic relationship were more likely to improve
the alliance than therapists who were less focused on the relationship.
As noted earlier, Foreman and Marmar (1985) suggested that
therapists may be able to improve the alliance by dealing with the
therapy relationship directly.
Other studies have implied that therapists who relate effectively to
patients influence the rate of patients' dropout (McLellan et al. 1988)
and the level of patients’ motivation (Miller and Rollnick 1991).
238
Interpreting Accurately. The accuracy of the therapist's
interpretations appears to be associated with development of the
therapeutic alliance (Crits-Christoph et al. 1993). The measure of
accuracy of interpretation is based on the congruence of the
therapist's interpretations with the patient's core conflictual
relationship theme (CCRT), particularly accuracy on the CCRT
dimensions of wish plus response from others; this congruence
measure predicted changes in the therapeutic alliance. In an earlier
study (Crits-Christoph et al. 1988), this congruence was associated
with the patients' benefits from psychotherapy.
ADVANCING THE BENEFICIAL POWER OF THE TREATMENT
ORGANIZATION
The qualities of the organization within which drug and alcohol
treatment are given can strongly influence the alliance of patients
who enter it. Among the earliest contributions in this area was the
work of Ball and Ross (1991). McLellan and associates (McLellan
and Durell 1995; McLellan et al., in press) have assembled a sample of
about 200 such treatment organizations and are systematically
relating the qualities of the organization, such as its supportiveness, to
outcomes of treatment and to patient characteristics. A large
collection of data on such organizations is also being assembled by
Hser and associates (1992). This kind of information is probably
more critically important for substance abuse patients whose
treatment often takes place in a clinic setting.
THE ROLE OF REWARDS
Two other treatment procedures are very likely to foster the alliance.
One is giving money as a reward when the patient successfully
achieves goals such as abstinence. Stanton and Todd (1981) showed
that giving money to the family for attendance and successful
abstinence by the patient was effective. Higgins and Budney (1993)
demonstrated that giving vouchers to patients was related to
attendance, and attendance was related to continued cocaine
abstinence and attendance at sessions. The effect of the vouchers
may be to encourage patients to come more often, thus improving
benefits. A more complex explanation is that as a result of coming
more often, the patient may develop an alliance and then benefit
239
more. The presence of the intervening variable of developing an
alliance is a probable inference that merits investigation.
Giving food, such as sandwiches and coffee, is another treatment aid
that appears to have similar benefits; the same explanatory reasoning
applies. The giver of the food is presumed to become associated with
food, a powerful unconditioned reinforcer, which may help the
alliance. Food also seems to help with attendance, which generally
leads to increased benefits from treatment, but controlled studies on
this have not yet been done.
All of these clinical and clinical-quantitative procedures appear to
stimulate the alliance and so will have positive effects on the patient's
improvement. These procedures may have a not-so-secret underlying
common source of their benefits in stimulating the alliance. It
becomes easier to recognize the commonality among the measures
after slowly re-reading the list of alliance-stimulating procedures: The
more the patient sees the therapist and the treatment organization as
providing what the patient needs, the more the procedure qualifies as
an alliance stimulant; the more that is given by the organization, the
more the patient experiences caring and support in achieving the
mutually agreed-upon goals.
ACKNOWLEDGMENT
Partially supported by NIDA Research Scientist Award DA 0016823A and NIDA grant 5418 DA07085 (to Lester Luborsky), by
National Institute of Mental Health Clinical Research Center grant
P50 MH45178 and Coordinating Center Grant U18-DA07090 (to
Paul Crits-Christoph), and the Treatment Research Unit of the
Department of Psychiatry, University of Pennsylvania (Charles
O'Brien).
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Predicting the outcomes of psychotherapy by the Penn
Helping Alliance Rating Method. Arch Gen Psych 39:397402, 1982.
Rogers, C. The necessary and sufficient conditions of therapeutic
personality change. J Consult Psychol 21:95-103, 1957.
Safran, J.; Crocker, P.; McMain, S.; and Murray, P. The therapeutic
alliance rupture as a therapy event for empirical
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Safran, J.; Muran, J.; and Wallner, L.K. Resolving therapeutic ruptures: A
task analytic investigation. In: Horvath, A., and
Greenberg, L., eds. The Working Alliance: Theory,
Research, and Practice. New York: Wiley, 1994.
Stanton, M.D., and Todd, T.C., eds. The Family Therapy of Drug
Addiction. New York: Guilford Press, 1981.
Woody, G.; Luborsky, L.; McLellan, A.T.; O'Brien, C.; Beck, A.T.; Blaine,
J.; Herman, I.; and Hole, A.V. Psychotherapy for opiate
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243
AUTHORS
Lester Luborsky, Ph.D.
Professor of Psychology in Psychiatry
Jacques Barber, Ph.D.
Assistant Professor of Psychology in Psychiatry
Lynne Siqueland, Ph.D.
Assistant Professor of Psychology in Psychiatry
A. Thomas McLellan, Ph.D.
Professor of Psychology inPsychiatry
George Woody, M.D.
Professor of Psychiatry
University of Pennsylvania
514 Spruce Street
Philadelphia, PA 19106
244
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26
THE BEHAVIORAL ASPECTS OF
SMOKING.
Norman A. Krasnegor, Ph.D., ed. (Reprint from 1979 Surgeon General's
Report on Smoking and Health.)
NCADI #M26
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THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL FLUIDS.
Richard L. Hawks, Ph.D., ed.
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PHARMACOLOGICAL ADJUNCTS IN SMOKING CESSATION. John
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MECHANISMS OF TOLERANCE AND DEPENDENCE.
Charles Wm. Sharp, Ph.D., ed.
NCADI #M54
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ETIOLOGY OF DRUG ABUSE: IMPLICATIONS FOR PREVENTION.
Coryl LaRue Jones, Ph.D., and
Robert J. Battjes, D.S.W., eds.
NCADI #M56
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61
COCAINE USE IN AMERICA: EPIDEMIOLOGIC AND CLINICAL
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Edgar H. Adams, M.S., eds.
NCADI #M61
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62
NEUROSCIENCE METHODS IN DRUG ABUSE RESEARCH.
Roger M. Brown, Ph.D., and David P. Friedman, Ph.D., eds.
NCADI #M62
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63
PREVENTION RESEARCH: DETERRING DRUG ABUSE AMONG
CHILDREN AND ADOLESCENTS. Catherine S. Bell, M.S., and Robert
J. Battjes, D.S.W., eds.
NCADI #M63
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64
PHENCYCLIDINE: AN UPDATE. Doris H. Clouet, Ph.D., ed.
NCADI #M64
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65
WOMEN AND DRUGS: A NEW ERA FOR RESEARCH.
Barbara A. Ray, Ph.D., and Monique C. Braude, Ph.D., eds.
NCADI #M65
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69 OPIOID PEPTIDES: MEDICINAL CHEMISTRY.
Rao S. Rapaka, Ph.D.; Gene Barnett, Ph.D.; and
Richard L. Hawks, Ph.D., eds.
NCADI #M69
NTIS PB #89-158422/AS (A17) $44.50
246
70
OPIOID PEPTIDES: MOLECULAR PHARMACOLOGY,
BIOSYNTHESIS, AND ANALYSIS. Rao S. Rapaka, Ph.D., and Richard L.
Hawks, Ph.D., eds.
NCADI #M70
NTIS PB #89-158430/AS (A18) $52.00
72
RELAPSE AND RECOVERY IN DRUG ABUSE.
Frank M. Tims, Ph.D., and Carl G. Leukefeld, D.S.W., eds.
NCADI #M72
NTIS PB #89-151963/AS (A09) $36.50
74
NEUROBIOLOGY OF BEHAVIORAL CONTROL IN DRUG ABUSE.
Stephen I. Szara, M.D., D.Sc., ed.
NCADI #M74
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77
ADOLESCENT DRUG ABUSE: ANALYSES OF TREATMENT
RESEARCH. Elizabeth R. Rahdert, Ph.D., and
John Grabowski, Ph.D., eds.
NCADI #M77
NTIS PB #89-125488/AS (A0) $27.00
78
THE ROLE OF NEUROPLASTICITY IN THE RESPONSE TO DRUGS.
David P. Friedman, Ph.D., and
Doris H. Clouet, Ph.D., eds.
NCADI #M78
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79
STRUCTURE-ACTIVITY RELATIONSHIPS OF THE CANNABINOIDS.
Rao S. Rapaka, Ph.D., and
Alexandros Makriyannis, Ph.D., eds.
NCADI #M79
NTIS PB #89-109201/AS (A10) $36.50
80
NEEDLE SHARING AMONG INTRAVENOUS DRUG ABUSERS:
NATIONAL AND INTERNATIONAL PERSPECTIVES. Robert J. Battjes,
D.S.W., and
Roy W. Pickens, Ph.D., eds.
NCADI #M80
NTIS PB #88-236138/AS (A09) $36.50
82
OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty, Ph.D., and
David P. Friedman, Ph.D., eds.
NCADI #M82
NTIS PB #88-245691/AS (A06) $27.00
83
HEALTH HAZARDS OF NITRITE INHALANTS.
Harry W. Haverkos, M.D., and John A. Dougherty, Ph.D., eds.
NCADI #M83
NTIS PB #89-125496/AS (A06) $27.00
84
LEARNING FACTORS IN SUBSTANCE ABUSE.
Barbara A. Ray, Ph.D., ed.
NCADI #M84
NTIS PB #89-125504/AS (A10) $36.50
247
85
EPIDEMIOLOGY OF INHALANT ABUSE: AN UPDATE.
Raquel A. Crider, Ph.D., and Beatrice A. Rouse, Ph.D., eds.
NCADI #M85
NTIS PB #89-123178/AS (A10) $36.50
86
COMPULSORY TREATMENT OF DRUG ABUSE: RESEARCH AND
CLINICAL PRACTICE. Carl G. Leukefeld, D.S.W., and Frank M. Tims,
Ph.D., eds.
NCADI #M86
NTIS PB #89-151997/AS (A12) $36.50
87
OPIOID PEPTIDES: AN UPDATE. Rao S. Rapaka, Ph.D., and
Bhola N. Dhawan, M.D., eds.
NCADI #M87
NTIS PB #89-158430/AS (A11) $36.50
88
MECHANISMS OF COCAINE ABUSE AND TOXICITY.
Doris H. Clouet, Ph.D.; Khursheed Asghar, Ph.D.; and
Roger M. Brown, Ph.D., eds.
NCADI #M88
NTIS PB #89-125512/AS (A16) $44.50
89
BIOLOGICAL VULNERABILITY TO DRUG ABUSE.
Roy W. Pickens, Ph.D., and Dace S. Svikis, B.A., eds.
NCADI #M89
NTIS PB #89-125520/AS (A09) $27.00
92
TESTING FOR ABUSE LIABILITY OF DRUGS IN HUMANS.
Marian W. Fischman, Ph.D., and Nancy K. Mello, Ph.D., eds.
NCADI #M92
NTIS PB #90-148933/AS (A17) $44.50
93
AIDS AND INTRAVENOUS DRUG USE: FUTURE DIRECTIONS FOR
COMMUNITY-BASED PREVENTION RESEARCH. Carl G. Leukefeld,
D.S.W.; Robert J. Battjes, D.S.W.; and Zili Amsel, D.S.C., eds.
NCADI #M93
NTIS PB #90-148933/AS (A14) $44.50
94
PHARMACOLOGY AND TOXICOLOGY OF AMPHETAMINE AND
RELATED DESIGNER DRUGS. Khursheed Asghar, Ph.D., and Errol De
Souza, Ph.D., eds.
NCADI #M94
NTIS PB #90-148958/AS (A16) $44.50
95
PROBLEMS OF DRUG DEPENDENCE, 1989. PROCEEDINGS OF THE
51st ANNUAL SCIENTIFIC MEETING. THE COMMITTEE ON
PROBLEMS OF DRUG DEPENDENCE, INC.
Louis S. Harris, Ph.D., ed.
NCADI #M95
NTIS PB #90-237660/AS (A99) $67.00
96
DRUGS OF ABUSE: CHEMISTRY, PHARMACOLOGY,
IMMUNOLOGY, AND AIDS. Phuong Thi Kim Pham, Ph.D., and
Kenner Rice, Ph.D., eds.
NCADI #M96
NTIS PB #90-237678/AS (A11) $36.50
97
NEUROBIOLOGY OF DRUG ABUSE: LEARNING AND MEMORY.
Lynda Erinoff, Ph.D., ed.
NCADI #M97
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98
THE COLLECTION AND INTERPRETATION OF DATA FROM
HIDDEN POPULATIONS.
Elizabeth Y. Lambert, M.S., ed.
NCADI #M98
NTIS PB #90-237694/AS (A08) $27.00
248
99
RESEARCH FINDINGS ON SMOKING OF ABUSED SUBSTANCES. C.
Nora Chiang, Ph.D., and
Richard L. Hawks, Ph.D., eds.
NCADI #M99
NTIS PB #91-141119 (A09) $27.00
100 DRUGS IN THE WORKPLACE: RESEARCH AND EVALUATION
DATA. VOL II. Steven W. Gust, Ph.D.; J. Michael Walsh, Ph.D.; Linda B.
Thomas, B.S.; and
Dennis J. Crouch, M.B.A., eds.
NCADI #M100
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101 RESIDUAL EFFECTS OF ABUSED DRUGS ON BEHAVIOR.
John W. Spencer, Ph.D., and John J. Boren, Ph.D., eds.
NCADI #M101
NTIS PB #91-172858/AS (A09) $27.00
102 ANABOLIC STEROID ABUSE. Geraline C. Lin, Ph.D., and
Lynda Erinoff, Ph.D., eds.
NCADI #M102
NTIS PB #91-172866/AS (A11) $36.50
103 DRUGS AND VIOLENCE: CAUSES, CORRELATES, AND
CONSEQUENCES. Mario De La Rosa, Ph.D.;
Elizabeth Y. Lambert, M.S.; and Bernard Gropper, Ph.D., eds.
NCADI #M103
NTIS PB #91-172874/AS (A13) $36.50
104 PSYCHOTHERAPY AND COUNSELING IN THE TREATMENT OF
DRUG ABUSE. Lisa Simon Onken, Ph.D., and Jack D. Blaine, M.D., eds.
NCADI #M104
NTIS PB #91-172874/AS (A07) $27.00
106 IMPROVING DRUG ABUSE TREATMENT.
Roy W. Pickens, Ph.D.; Carl G. Leukefeld, D.S.W.; and
Charles R. Schuster, Ph.D., eds.
NCADI #M106
NTIS PB #92-105873(A18) $50.00
107 DRUG ABUSE PREVENTION INTERVENTION RESEARCH:
METHODOLOGICAL ISSUES. Carl G. Leukefeld, D.S.W., and William J.
Bukoski, Ph.D., eds.
NCADI #M107
NTIS PB #92-160985 (A13) $36.50
108 CARDIOVASCULAR TOXICITY OF COCAINE: UNDERLYING
MECHANISMS. Pushpa V. Thadani, Ph.D., ed.
NCADI #M108
NTIS PB #92-106608 (A11) $36.50
109 LONGITUDINAL STUDIES OF HIV INFECTION IN INTRAVENOUS
DRUG USERS: METHODOLOGICAL ISSUES IN NATURAL HISTORY
RESEARCH. Peter Hartsock, Dr.P.H., and Sander G. Genser, M.D., M.P.H.,
eds.
NCADI #M109
NTIS PB #92-106616 (A08) $27.00
111 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH:
RECEPTOR CLONING, NEUROTRANSMITTER EXPRESSION, AND
MOLECULAR GENETICS: VOLUME I. Theresa N.H. Lee, Ph.D., ed.
NCADI #M111
NTIS PB #92-135743 (A10) $36.50
112 EMERGING TECHNOLOGIES AND NEW DIRECTIONS IN DRUG
ABUSE RESEARCH. Rao S. Rapaka, Ph.D.;
Alexandros Makriyannis, Ph.D.; and Michael J. Kuhar, Ph.D., eds.
NCADI #M112
NTIS PB #92-155449 (A15) $44.50
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113 ECONOMIC COSTS, COST EFFECTIVENESS, FINANCING, AND
COMMUNITY-BASED DRUG TREATMENT.
William S. Cartwright, Ph.D., and James M. Kaple, Ph.D., eds.
NCADI #M113
NTIS PB #92-155795 (A10) $36.50
114 METHODOLOGICAL ISSUES IN CONTROLLED STUDIES ON
EFFECTS OF PRENATAL EXPOSURE TO DRUG ABUSE.
M. Marlyne Kilbey, Ph.D., and Khursheed Asghar, Ph.D., eds.
NCADI #M114
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115 METHAMPHETAMINE ABUSE: EPIDEMIOLOGIC ISSUES AND
IMPLICATIONS. Marissa A. Miller, D.V.M., M.P.H., and
Nicholas J. Kozel, M.S., eds.
NCADI #M115
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116 DRUG DISCRIMINATION: APPLICATIONS TO DRUG ABUSE
RESEARCH. R.A. Glennon, Ph.D.;
Toubjörn U.C. Järbe, Ph.D.; and J. Frankenheim, Ph.D., eds.
NCADI #M116
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117 METHODOLOGICAL ISSUES IN EPIDEMIOLOGY, PREVENTION,
AND TREATMENT RESEARCH ON DRUG-EXPOSED WOMEN AND
THEIR CHILDREN.
M. Marlyve Kilbey, Ph.D., and Kursheed Asghar, Ph.D., eds.
GPO Stock #O17-024-01472-9 $12.00
NCADI #M117
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118 DRUG ABUSE TREATMENT IN PRISONS AND JAILS.
Carl G. Leukefeld, D.S.W., and Frank M. Tims, Ph.D., eds.
GPO Stock #O17-024-01473-7 $16.00
NCADI #M118
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120 BIOAVAILABILITY OF DRUGS TO THE BRAIN AND THE BLOODBRAIN BARRIER. Jerry Frankenheim, Ph.D., and
Roger M. Brown, Ph.D., eds.
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NCADI #M120
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121 BUPRENORPHINE: AN ALTERNATIVE TREATMENT FOR OPIOID
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123 ACUTE COCAINE INTOXICATION: CURRENT METHODS OF
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NCADI #M123
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124 NEUROBIOLOGICAL APPROACHES TO BRAIN-BEHAVIOR
INTERACTION. Roger M. Brown, Ph.D., and
Joseph Fracella, Ph.D., eds.
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NCADI #M124
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125 ACTIVATION OF IMMEDIATE EARLY GENES BY DRUGS OF
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250
126 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH
VOLUME II: STRUCTURE, FUNCTION, AND EXPRESSION. Theresa N.H.
Lee, Ph.D., ed.
NCADI #M126
NTIS PB #94-169497 (A08) $27.00
127 PROGRESS AND ISSUES IN CASE MANAGEMENT.
Rebecca S. Ashery, D.S.W., ed.
NCADI #M127
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128 STATISTICAL ISSUES IN CLINICAL TRIALS FOR TREATMENT OF
OPIATE DEPENDENCE.
Ram B. Jain, Ph.D., ed.
NCADI #M128
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129 INHALANT ABUSE: A VOLATILE RESEARCH AGENDA. Charles W.
Sharp, Ph.D.; Fred Beauvais, Ph.D.; and
Richard Spence, Ph.D., eds.
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NCADI #M129
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130 DRUG ABUSE AMONG MINORITY YOUTH: ADVANCES IN
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NCADI #M130
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131 IMPACT OF PRESCRIPTION DRUG DIVERSION CONTROL
SYSTEMS ON MEDICAL PRACTICE AND PATIENT CARE.
James R. Cooper, Ph.D.; Dorynne J. Czechowicz, M.D.;
Stephen P. Molinari, J.D., R.Ph.; and
Robert C. Peterson, Ph.D., eds.
GPO Stock #017-024-01505-9 $14.00
NCADI #M131
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132 PROBLEMS OF DRUG DEPENDENCE, 1992: PROCEEDINGS OF THE
54TH ANNUAL SCIENTIFIC MEETING OF THE COLLEGE ON
PROBLEMS OF DRUG DEPENDENCE.
Louis Harris, Ph.D., ed.
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133 SIGMA, PCP, AND NMDA RECEPTORS.
Errol B. De Souza, Ph.D.; Doris Clouet, Ph.D., and
Edythe D. London, Ph.D., eds.
NCADI #M133
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134 MEDICATIONS DEVELOPMENT: DRUG DISCOVERY, DATABASES,
AND COMPUTER-AIDED DRUG DESIGN.
Rao S. Rapaka, Ph.D., and Richard L. Hawks, Ph.D., eds.
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NCADI #M134
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135 COCAINE TREATMENT: RESEARCH AND CLINICAL
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NCADI #M135
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136 ASSESSING NEUROTOXICITY OF DRUGS OF ABUSE.
Lynda Erinoff, Ph.D., ed.
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NCADI #M136
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137 BEHAVIORAL TREATMENTS FOR DRUG ABUSE AND
DEPENDENCE. Lisa Simon Onken, Ph.D.; Jack D. Blaine, M.D.; and John J.
Boren, Ph.D., eds.
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NCADI #M137
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138 IMAGING TECHNIQUES IN MEDICATIONS DEVELOPMENT:
CLINICAL AND PRECLINICAL ASPECTS. Heinz Sorer, Ph.D., and Rao S.
Rapaka, Ph.D., eds.
NCADI #M138
139 SCIENTIFIC METHODS FOR PREVENTION INTERVENTION
RESEARCH. Arturo Cazares, M.D., M.P.H., and
Lula A. Beatty, Ph.D., eds.
NCADI #M139
140 PROBLEMS OF DRUG DEPENDENCE, 1993: PROCEEDINGS OF THE
55TH ANNUAL SCIENTIFIC MEETING, THE COLLEGE ON PROBLEMS
OF DRUG DEPENDENCE, INC. VOLUME I: PLENARY SESSION
SYMPOSIA AND ANNUAL REPORTS. Louis S. Harris, Ph.D., ed.
NCADI #M140
141 PROBLEMS OF DRUG DEPENDENCE, 1993: PROCEEDINGS OF THE
55TH ANNUAL SCIENTIFIC MEETING, THE COLLEGE ON PROBLEMS
OF DRUG DEPENDENCE, INC. VOLUME II: ABSTRACTS. Louis S. Harris,
Ph.D., ed.
NCADI #M141
142 ADVANCES IN DATA ANALYSIS FOR PREVENTION
INTERVENTION RESEARCH. Linda M. Collins, Ph.D., and
Larry A. Seitz, Ph.D., eds.
NCADI #M142
143 THE CONTEXT OF HIV RISK AMONG DRUG USERS AND THEIR
SEXUAL PARTNERS. Robert J. Battjes, D.S.W.;
Zili Sloboda, Sc.D.; and William C. Grace, Ph.D., eds.
NCADI #M143
144 THERAPEUTIC COMMUNITY: ADVANCES IN RESEARCH
AND APPLICATION. Frank M. Tims, Ph.D.;
George De Leon, Ph.D.; and Nancy Jainchill, Ph.D., eds.
NCADI #M144
145 NEUROBIOLOGICAL MODELS FOR EVALUATING MECHANISMS
UNDERLYING COCAINE ADDICTION.
Lynda Erinoff, Ph.D., and Roger M. Brown, Ph.D., eds.
NCADI #M145
146 HALLUCINOGENS: AN UPDATE. Geraline C. Lin, Ph.D., and Richard
A. Glennon, Ph.D., eds.
NCADI #M146
252
147 DISCOVERY OF NOVEL OPIOID MEDICATIONS.
Rao S. Rapaka, Ph.D., and Heinz Sorer, Ph.D., eds.
NCADI #M147
148 EPIDEMIOLOGY OF INHALANT ABUSE: AN INTERNATIONAL
PERSPECTIVE.
Nicholas J. Kozel, M.S.; Zili Sloboda, Sc.D.;
and Mario R. De La Rosa, Ph.D., eds.
NCADI #M148
149 MEDICATIONS DEVELOPMENT FOR THE TREATMENT OF
PREGNANT ADDICTS AND THEIR INFANTS.
C. Nora Chiang, Ph.D., and Loretta P. Finnegan, M.D., eds.
NCADI #M149
150 INTEGRATING BEHAVIORAL THERAPIES WITH MEDICATIONS
IN THE TREATMENT OF DRUG DEPENDENCE. Lisa Simon Onken,
Ph.D.; Jack D. Blaine, M.D.; and John J. Boren, Ph.D., eds.
NCADI #M150
253
151 SOCIAL NETWORKS, DRUG ABUSE, AND HIV TRANSMISSION.
Richard H. Needle, Ph.D., M.P.H.;
Susan L. Coyle, Ph.D.; Sander G. Genser, M.D., M.P.H.; and
Robert T. Trotter II, Ph.D., eds.
NCADI #M151
152 PROBLEMS OF DRUG DEPENDENCE, 1993: PROCEEDINGS OF THE
56TH ANNUAL SCIENTIFIC MEETING, THE COLLEGE ON PROBLEMS
OF DRUG DEPENDENCE, INC. VOLUME I: PLENARY SESSION
SYMPOSIA AND ANNUAL REPORTS. Louis S. Harris, Ph.D., ed.
NCADI #M152
153 PROBLEMS OF DRUG DEPENDENCE, 1993: PROCEEDINGS OF THE
56TH ANNUAL SCIENTIFIC MEETING, THE COLLEGE ON PROBLEMS
OF DRUG DEPENDENCE, INC. VOLUME II: ABSTRACTS. (1995) Louis
S. Harris, Ph.D., ed.
NCADI #M153
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154 MEMBRANES AND BARRIERS: TARGETED DRUG DELIVERY.
(1995) Rao S. Rapaka, Ph.D., ed.
NCADI #M154
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155 REVIEWING THE BEHAVIORAL SCIENCE KNOWLEDGE BASE ON
TECHNOLOGY TRANSFER. (1995)
Thomas E. Backer, Ph.D.; Susan L. David; and Gerald Soucy, Ph.D., eds.
NCADI #M155
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156 ADOLESCENT DRUG ABUSE: CLINICAL ASSESSMENT AND
THERAPEUTIC INTERVENTIONS. (1995)
Elizabeth Rahdert, Ph.D.; Zili Sloboda, Ph.D.; and Dorynne Czechowicz,
M.D., eds.
NCADI #M156
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157 QUALITATIVE METHODS IN DRUG ABUSE AND HIV RESEARCH.
(1995)
Elizabeth Y. Lambert, M.Sc.; Rebecca S. Ashery, D.S.W.; and Richard H.
Needle, Ph.D., M.P.H., eds.
NCADI #M157
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158 BIOLOGICAL MECHANISMS AND PERINATAL EXPOSURE TO
DRUGS. (1995) Pushpa V. Thadani, Ph.D., ed.
NCADI #M158
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159 INDIVIDUAL DIFFERENCES IN THE BIOBEHAVIORAL ETIOLOGY
OF DRUG ABUSE. (1996) Harold W. Gordon, Ph.D., and Meyer D. Glantz,
Ph.D., eds.
NCADI #M159
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161 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH.
VOLUME III: RECENT ADVANCES AND EMERGING STRATEGIES.
(1996) Theresa N.H. Lee, Ph.D., ed.
NCADI #M161
162 PROBLEMS OF DRUG DEPENDENCE, 1995. PROCEEDINGS FROM
THE 57TH ANNUAL SCIENTIFIC MEETING OF THE COLLEGE ON
DRUG DEPENDENCE, INC. (1996)
Louis Harris, Ph.D., ed.
NCADI #M162
163 NEUROTOXICITY AND NEUROPATHOLOGY ASSOCIATED WITH
COCAINE/STIMULANT ABUSE. (1996)
Dorota Majewska, Ph.D., ed.
NCADI #M163
164 BEHAVIORAL STUDIES OF DRUG-EXPOSED OFFSPRING:
METHODOLOGICAL ISSUES IN HUMAN AND ANIMAL RESEARCH.
(1996) Cora Lee Wetherington, Ph.D.;
Vincent L. Smeriglio, Ph.D.; and Loretta P. Finnegan, Ph.D., eds.
NCADI #M164
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