Length of stay as a predictor of reliable change in psychological recovery and well being following residential substance abuse treatment

Finding the optimal length of stay for veterans in substance use disorder residential treatment using generalized propensity score modeling

Substance use disorder (SUD) residential treatment provides critical services to patients with complex clinical needs. The Department of Veterans Affairs (VA) has over 70 SUD residential programs to meet the needs of veterans with severe SUD. Prior research is mixed on what SUD residential length of stay (LOS) duration maximizes average treatment outcomes, with some studies advocating for around 30 days and others advocating for at least 90 days. Much of this research is limited by methodological issues and fails to consider both outcomes for established patients and timely access for prospective patients. The present study sought to clarify the relative benefits of different LOSs to be considered by SUD residential program decision-makers as default LOSs, upon which to be personalized by individual patient needs and clinical assessment. Using medical record data associated with N = 15,889 veterans discharging from a VA SUD residential center between 10/1/2021 and 9/30/2022, we identified an optimal LOS range balancing average treatment outcomes and ensuring new patient access/minimizing established patient diminished returns from treatment. Using a generalized propensity-weighted dose-response curve, we identified key LOSs between 35 and 49 days with different tradeoffs between enhancing outcomes and access.

The path of therapeutic community process experience to recovery capital and psychological well-being as mediated by group working alliance: the role of locus-of-hope

The therapeutic community (TC) is a social-learning treatment program for people with substance use disorders (PSUDs). Most studies focused on how the TC program facilitates positive recovery outcomes. Less emphasis was given to ethnically relevant patient dispositions that may influence the TC process from a collectivist context, especially from Asian developing countries like the Philippines. In this study, we tested the TC process experience's (TCPE) path to recovery capital (RC) and psychological well-being (PWB) as mediated by group working alliance (GWA). We also examined if PSUDs' locus-of-hope (LOH), or the person's goal-pursuit disposition involving external co-agencies like peers, family, and spirit, interact with this mechanism. A total of 451 male PSUDs from TC facilities in the Philippines were surveyed, with 406 participants included in the final analysis. Results showed that the participants' TCPE predicted RC and PWB. The direct pathways were mediated by GWA. There were no significant mediation effects among patients with high internal and external-peer LOH. Moreover, there were significant mediation effects among patients with high external-family and external-spirit LOH. The results suggest the contributions of PSUDs' LOH dispositions to the TC mechanism from a collectivist population, thus revealing nuances of the TC model applied in a vulnerable ethnic context.

Duration of stay and rate of subsequent criminal conviction and hospitalisation for substance use among young people admitted to a short-term residential program

INTRODUCTION

This study examined the association between program duration and rate of criminal conviction and hospitalisation for substance use up to 15 years later among young people admitted to a short-term residential program for drug and alcohol use.

METHODS

Data were derived from linked administrative records of all clients referred to a modified therapeutic community for young people from January 2001 to December 2016 in New South Wales, Australia (n = 3059). Cox proportional hazards regression analyses examined the rate of conviction (separately for any offence, violent offence, non-violent offence and administrative offence) and hospitalisation for substance use, up to 15 years post-program among young people who attended treatment for 1-29 days, 30-59 days, 60-89 days and 90-120 days.

RESULTS

Thirty days or more in treatment was independently associated with a lower rate of conviction for any offence and a non-violent offence, as well as hospitalisation for substance use, while 60 days or more was associated with a lower rate of conviction for a violent and administrative offence, relative to those who spent 1-29 days in the program. Additional months in the program were also associated with reduced rates of conviction and hospitalisation, although 90-120 days appeared to confer no additional benefits than 60-89 days.

DISCUSSION AND CONCLUSIONS

At least 60 days may be the minimum duration needed for short-term, therapeutic community programs to reduce the risk of conviction across all crime types and hospitalisation for substance use.

Does knowledge of liver fibrosis affect high-risk drinking behaviour (KLIFAD): an open-label pragmatic feasibility randomised controlled trial

Background

Early identification followed by effective behaviour interventions is pivotal to changing the natural history of alcohol-related liver disease. We examined the feasibility of using transient elastography based advice and alcohol recovery video stories (ARVS) to change drinking behaviour in community alcohol services.

Methods

A feasibility randomised control trial (RCT) was conducted in three community alcohol services. Adults 18+ years presenting with a primary alcohol problem were randomised (1:1) to receive either usual care (control group) or usual care and the KLIFAD Intervention, consisting of advice tailored to liver stiffness measure and access to ARVS (intervention group). Data were collected at baseline and six months. To establish definitive trial feasibility, recruitment and retention rates, study procedure safety and extent of effectiveness were measured (Start date: 02.10.2019, End date: 30.11.2022, ISRCTN.com: 16922410).

Findings

382 service users were screened, 184 were randomised (intervention: 93, control: 91), and baseline data were collected for 128 (intervention: 71, control: 59). Six months follow-up data were available in 87 (intervention: 53, control: 34). Intervention compared to the control group had a longer duration of engagement with services (mean difference 8.6 days SD = 18.4), was more likely to complete the allocated treatment program and reduced or stop drinking (54.9% vs 43.9%) and reduce AUDIT category (71.7% vs 61.8%). There were no reported serious adverse reactions, one intervention group participant reported an increase in AUDIT category.

Interpretation

Integration of transient elastography in community alcohol services is feasible. It may improve engagement with services, retention in clinical trials and supplement the reduction in self-reported alcohol consumption. A definitive RCT is supported.

Funding

National Institute for Health and Care Research (NIHR201146).

Substance use, risk behaviours and well-being after admission to a quasi-residential abstinence-based rehabilitation programme: 4-year follow-up

BACKGROUND

Tackling Scotland's drug-related deaths and improving outcomes from substance misuse treatments, including residential rehabilitation, is a national priority.

AIMS

To analyse and report outcomes up to 4 years after attendance at a substance misuse residential rehabilitation programme (Lothians and Edinburgh Abstinence Programme).

METHOD

In total, 145 participants were recruited to this longitudinal quantitative cohort study of an abstinence-based residential rehabilitation programme based on the therapeutic community model; 87 of these participants were followed up at 4 years. Outcomes are reported for seven subsections of the Addiction Severity Index-X (ASI-X), together with frequency of alcohol use, heroin use, injecting drug use and rates of abstinence from substances of misuse.

RESULTS

Significant improvement in most outcomes at 4 years compared with admission scores were found. Completing the programme was associated with greater rates of abstinence, reduced alcohol use and improvements in alcohol status score (Mann-Whitney U = 626, P = 0.013), work satisfaction score (U = 596, P = 0.016) and psychiatric status score (U = 562, P = 0.007) on the ASI-X, in comparison with non-completion. Abstinence rates improved from 12% at baseline to 48% at 4 years, with the rate for those completing the programme increasing from 14.5% to 60.7% (χ²(2, 87) = 9.738, P = 0.002). Remaining abstinent from substances at follow-up was associated with better outcomes in the medical (U = 540, P < 0.001), psychiatric (U = 273.5, P < 0.001) and alcohol (U = 322.5, P < 0.001) subsections of the ASI-X.

CONCLUSIONS

Attending this abstinence-based rehabilitation programme was associated with positive changes in psychological and social well-being and harm reduction from substance use at 4-year follow-up, with stability of change from years 1 to 4.

Alcohol, tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factors

BACKGROUND

Substance use contributes to poor health and increases the risk of mortality in the homeless population. This study assessed the prevalence and risk levels of substance use and associated factors among adults experiencing homelessness in Accra, Ghana.

METHODS

305 adults currently experiencing sheltered and unsheltered homelessness in Accra aged ≥ 18 years were recruited. The World Health Organization's (WHO) Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was used to assess substance use risk levels. Association of high-risk substance use with sociodemographic, migration, homelessness, and health characteristics were assessed using logistic regression.

RESULTS

Nearly three-quarters (71%, n = 216) of the sample had ever used a substance, almost all of whom engaged in ASSIST-defined moderate-risk (55%) or high-risk (40%) use. Survivors of physical or emotional violence (AOR = 3.54; 95% confidence interval [CI] 1.89-6.65, p<.001) and sexual violence (AOR = 3.94; 95%CI 1.85-8.39, p<.001) had significantly higher odds of engaging in high-risk substance use, particularly alcohol, cocaine, and cannabis. The likelihood of engaging in high-risk substance use was higher for men than women (AOR = 4.09; 95%CI 2.06-8.12, p<.001) but lower for those in the middle-income group compared to low-income (AOR = 3.94; 95%CI 1.85-8.39, p<.001).

CONCLUSIONS

Risky substance use was common among adults experiencing homelessness in Accra, and strongly associated with violent victimisation, gender, and income levels. The findings highlight the urgent need for effective and targeted preventive and health-risk reduction strategies to address risky substance use in the homeless population in Accra and similar cities within Ghana and sub-Sahara Africa with a high burden of homelessness.

Health utilities among Aboriginal people attending residential rehabilitation services in New South Wales, Australia: An observational follow-up study

INTRODUCTION

There have been no published studies reporting health utilities among Aboriginal people attending residential rehabilitation for substance use treatment. This study aims to examine health utilities for Aboriginal people in residential rehabilitation and investigate the association between health utilities and length of stay.

METHODS

EuroQol-5 Dimension 5-level (EQ-5D-5L) raw data collected from three residential rehabilitation services in New South Wales, Australia was transferred into a quality-adjusted health index using EQ-5D-5L Crosswalk Index Value Calculator. Clients were categorised into two groups based on their length of stay in treatment: ≤60 days or more than 60 days. Among people who stay longer than 60 days, we also examined health utilities by exit status (yes/no). Bootstrapping was used to examine the difference in improvement in health utilities from baseline to the latest assessment in both groups.

RESULTS

Our study included 91 clients (mean age 32 years old SD: 9). Mean health utility at baseline was 0.76 (SD 0.25) and at the latest assessment was 0.88 (SD 0.16). For clients staying 60 days, the incremental health utility was 0.13 (95% confidence interval [CI] 0.06-0.20; p < 0.01). For clients staying less than or equal to 60 days, the incremental health utility was 0.12 (95% CI 0.00-0.24; p = 0.06). For the total sample, the incremental health utility was 0.12 (95% CI 0.06-0.19; p < 0.01).

DISCUSSION AND CONCLUSIONS

There is a significant improvement in health utilities for people staying longer in residential rehabilitation. Strategies to improve treatment retention could potentially increase quality of life for Aboriginal people in residential rehabilitation.

Impact of an osteopathic peer recovery coaching model on treatment outcomes in high-risk men entering residential treatment for substance use disorders

CONTEXT

The United States has witnessed a disproportionate rise in substance use disorders (SUD) and co-occurring mental health disorders, paired with housing instability, especially among racially minoritized communities. Traditional in-patient residential treatment programs for SUD have proven inconsistent in their effectiveness in preventing relapse and maintaining attrition among these patient populations. There is evidence showing that peer recovery programs led by individuals who have lived experience with SUD can increase social support and foster intrinsic motivation within participants to bolster their recovery. These peer recovery programs, when coupled with a standardized training program for peer recovery coaches, may be very efficacious at improving patient health outcomes, boosting performance on Substance Abuse and Mental Health Services Administration (SAMHSA) national outcome measures (NOMs), and helping participants build an overall better quality of life.

OBJECTIVES

The goal of this study is to highlight the efficacy of a peer recovery program, the Minority Aids Initiative, in improving health outcomes and associated NOMs in men with SUD and/or co-occurring mental health disorder.

METHODS

Participants received six months of peer recovery coaching from trained staff. Sessions were guided by the Manual for Recovery Coaching and focused on 10 different domains of recovery. Participants and coaches set long-term goals and created weekly action plans to work toward them. Standardized assessments (SAMHSA's Government Performance and Results Act [GPRA] tool, Addiction Severity Index [ASI]) were administered by recovery coaches at intake and at the 6-month time point to evaluate participant progress. Analyses of participant recovery were carried out according to SAMHSA's six NOMs and assessed the outcomes of the intervention and their significance.

RESULTS

A total of 115 participants enrolled in the program over a 2-year period. Among them, 53 were eligible for 6-month follow-up interviews. In total, 321 sessions were held, with an average of three sessions per participant. Participants showed marked improvement across five of the six NOMs at the end of the 6-month course and across all ASI outcomes, with the exception of three in which participants reported an absence or few symptoms at intake.

CONCLUSIONS

Our study shows that participants receive benefits across nearly all NOM categories when paired with recovery coaches who are well trained in medication-assisted treatment (MAT) and medications for opioid use disorder (MOUD) over a 6-month period. We see the following: a higher rate of abstinence; increased housing stability; lower health, behavioral, and social consequences; lower depression and anxiety; longer participant-recovery coach exposure time; and higher follow-up rates. We hope that our results can contribute to advancements and greater acceptance in the implementation of peer recovery coaching as well as an improvement in the lives of the communities affected by substance use.

Effects of a Residential Multimodal Psychological Treatment in an Addicted Population, at 6 and 12 Months: Differences Between Men and Women

The aim of this study is to explore the effects of a residential multimodal treatment intervention for an addict population. We gathered participants from the "Programa Base" (n = 166) of the Solidarity and Reinsertion Foundation of Murcia, and assessed the various problematic areas with the EuropASI at baseline level, 6 months and 12 months of treatment. We found improved outcomes in every area except for Legal Status. In addition, we found differences between male and female participants in their baseline evaluation, as well as between completers and non-completers. In conclusion, this data shows us some changes which occurred in individuals with problematic drug use during treatment, going further into the complex social reality which causes great suffering and damage to people and their families.

Examining Recovery Status Trends over 7-Years for Men and Women Clients of a Substance Use Disorder Recovery Housing Program

Adults who are homeless and/or involved in the criminal justice system have significantly higher risks of substance use disorders (SUD)s and they may have increased difficulty initiating and maintaining traditional SUD treatments. To address the needs of adults with SUDs who are homeless/criminal justice system involved the Recovery Kentucky programs were established. This study examined outcomes for this recovery housing program among an unduplicated statewide sample of men ( n=672) and women ( n = 732) clients who entered the Recovery Kentucky program and who were followed-up about 12 months after program entry across a 7-year period. Low, but similar rates of problem alcohol or illicit drug use at follow-up were found across the 7-year period. Men had higher rates of return to use than women. Further, about 40% of the clients had at least one recovery status vulnerability factor at follow-up each year of the study with no differences by gender.

Work-Related Satisfaction among Clinicians Working at Inpatient Treatment Facilities for Substance Use Disorder: The Role of Recovery Orientation

Several psychosocial factors have been suggested as facilitators of change among inpatients treated for substance use disorder (SUD). Research suggests that staff members are also influenced by the practice in which they are involved, and by contextual psychosocial factors at their treatment facilities. This cross-sectional questionnaire survey study was conducted to investigate the role of recovery-orientated interventions in describing work-related satisfaction among clinicians at inpatient SUD treatment facilities. The respondents (n = 407) rated items indicating work-related satisfaction and the degree of recovery orientation at their treatment facilities. The main findings of two block regression analyses indicated that clinicians’ work-related satisfaction was positively influenced by inpatients’ opportunities to pursue their goals and choices, and negatively influenced by inpatient involvement. The change in clinicians’ work-related satisfaction could not be described by the degree of individually tailored and varied interventions at the treatment facility. Clinicians should be supported and involved in the process of implementing measures to increase inpatient involvement in the treatment programmes, and treatment measures that enable inpatients to pursue their goals and choices should be enhanced. The findings of this and previous studies indicate that a recovery-oriented framework promotes clinicians’ work-related satisfaction and has an enabling influence on both inpatients and clinicians.

Examining Recovery Program Participants by Gender: Program Completion, Relapse, and Multidimensional Status 12 Months After Program Entry

This study examined individual-level characteristics and factors associated with program completion, relapse, and multidimensional status at follow-up for 213 men and 248 women who entered one of 17 peer-led recovery programs and who completed a follow-up interview 12 months later. Study results found that although there were some significant gender differences at program entry among participants entering Recovery Kentucky, there were few gender differences at follow-up. In addition, although participants had significant psychosocial problems, polysubstance use patterns, and severe substance use disorder (SUD), the majority of both men and women reported completing the program (80.3%), a small minority reported relapse (9.5%), and about one third had worse multidimensional status about 12 months after program entry. Lower quality of life rating at program entry was associated with program completion and with better multidimensional status at follow-up. Study results suggest the recovery program provides an important option for some of the most vulnerable individuals with SUD.

Recovery as Life Transformation: Examining the Relationships between Recovery, Hope, and Relapse

Models of holistic recovery that focus on wellbeing in recovery are emerging in the field of substance use treatment, but the literature shows little research on the mechanisms of change within these models. The authors present hope as significant factor. Although hope is a considered a vital factor of substance use recovery, empirical research on the relationships between recovery and hope is sparse. Objectives: The objectives of the study were to examine (a) the association between recovery progress on risk of relapse and (b) the mediating role of hope in the relationship between recovery progress and risk of relapse. Methods: Our cross-sectional study included a community sample of 412 U.S. adults. Using a structural equation model, we examined relationships among recovery progress, risk of relapse, and hope. Results: The mediation model indicated a significant negative relationship between recovery progress and risk of relapse. Furthermore, it demonstrated that hope partially mediates the effect of recovery progress on risk of relapse. Conclusions: The findings provide empirical support for holistic recovery models of recovery and prevention of relapse. Further implications of these findings are discussed.

Longitudinal Substance Use and Biopsychosocial Outcomes Following Therapeutic Community Treatment for Substance Dependence

The Therapeutic Community (TC) model is considered an effective treatment for substance dependence, particularly for individuals with complex presentations. While a popular approach for this cohort across a number of countries, few studies have focussed on biopsychosocial and longer-term outcomes for this treatment modality. This study reports on substance use, dependence, and biopsychosocial outcomes up to 9 months post-exit from two TC sites.

METHODS

A longitudinal cohort study (n = 166) with two follow-up time points. Measures included substance use, dependence, subjective well-being, social functioning, and mental and physical health. Generalized Linear Models were employed to assess change over time.

RESULTS

At 9 months, 68% of participants reported complete 90-day drug abstinence. Alcohol frequency and quantity were reduced by over 50% at 9 months, with 32% of the sample recording 90-day abstinence at 9 months. Both alcohol and drug dependence scores were reduced by over 60%, and small to medium effect sizes were found for a range of psychosocial outcomes at 9 months follow-up, including a doubling of wellbeing scores, and a halving of psychiatric severity scores. Residents who remained in the TC for at least 9 months reported substantially better outcomes.

CONCLUSIONS

With notably high study follow-up rates (over 90% at 9 months post-exit), these data demonstrate the value of the TC model in achieving substantial and sustained improvements in substance use and psychosocial outcomes for a cohort with severe substance dependence and complex presentations. Implications for optimal length of stay are discussed.

The recovery-oriented therapeutic community for addictions (ROTC): a response to contemporary substance use disorder treatments in the Philippines

Purpose

The Philippines’ nationwide campaign on drugs has been under the limelight due to its controversial approaches in dealing with the problem of addiction. Despite the government’s current efforts, substance use disorders continue to persist within the population. The purpose of this paper is to provide recommendations for addressing the issue of substance use disorder treatment through a modification of the therapeutic community (TC) in the Philippine context.

Design/methodology/approach

This conceptual paper reviews the existing facts about the Philippines’ campaign against drugs, the approaches implemented by the government, current state and research developments of TCs, and its resulting impact on contemporary evidence-based treatment for addiction in the country.

Findings

A treatment framework outlining a recovery-oriented therapeutic community (ROTC) is presented. The ROTC aims to address addiction as a chronic, relapsing disease. This alternative approach for addiction treatment in the Philippines is based on the concept of recovery, principles of effective substance use disorder treatment, and recent developments in TC best practices from the international community.

Originality/value

This paper discusses different recommendations for policy development, interventions and research, aimed at improving the odds of securing recovery for people suffering from addiction.

Measuring the performance of the Mental Health Continuum-Short Form (MHC-SF) in a primary care youth mental health service

Objectives

Mental health is regarded as more than the absence of mental health difficulties, with clinical and research focus moving towards measurement of well-being. The Mental Health Continuum-Short Form (MHC-SF) was developed to assess overall and emotional, social and psychological well-being. Little is known about the use of the MHC-SF with young people engaging with mental health services. The current pilot study sought to examine the performance of the MHC-SF in an Irish primary care youth mental health service for 12–25 year olds.

Methods

A sample of 229 young people (female n=143; male n=85, unknown n=1) aged 12–24 years (M=15.87, SD=2.51) who completed the MHC-SF prior to commencing their first intervention session in Jigsaw participated in this study. The psychometric properties of the MHC-SF were investigated using confirmatory factor analysis (CFA) and Cronbach’s alpha for internal consistency.

Results

CFA supported the three-factor structure of the MHC-SF for emotional, social, and psychological well-being, and very good internal consistency was observed.

Conclusion

Findings provide evidence for the psychometric properties of the MHC-SF in a primary care youth mental health setting, and suggest that the MHC-SF’s three-factor structure is valid for use in this context. Limitations and recommendations for future research are discussed.

An evaluation of the maintenance to abstinence (MTA) program in achieving abstinence in opioid users and improving mental health and quality of life

BACKGROUND

Residential opioid rehabilitation aims to improve the mental health and quality of life of opioid users through abstinence and residential program participation. This study aimed to determine the depression, anxiety, stress and quality of life amongst maintenance to abstinence (MTA) program residents. Secondary study aims were to assess the personal characteristics of MTA clients, addiction and risk taking behaviours, factors associated with program completion, as well as to assess the reliable change in participants' mental health and quality of life on exit.

METHODS

Retrospective analysis of routinely collected data (2013-2017) from surveys completed by 100 clients. Outcome measures were: Depression, Anxiety, Stress Score (DASS-42), World Health Organisation Quality of Life 8 questions (WHOQOL-8) and Kessler Psychological Distress Scale (K10). Other variables included demographics, drug use, other addictions, aggression, self-harm, suicidal ideation/attempts, and risk taking behaviours. Statistical methods included Chi-square, Fisher's exact, t-tests, repeated measures analysis of variance and the Reliable Change Index.

RESULTS

All mean DASS-42, WHOQOL-8 and K10 scores improved significantly in all participants from entry to exit (p < 0.001). The majority of participants demonstrated reliable improvement across all psychometric measures. Completion rates for the MTA program were 51%. Depression (p = 0.023), anxiety (p = 0.010) and stress (p = 0.015) DASS-42 scores decreased significantly more in completers compared to non-completers. The rate of improvement in mean WHOQOL-8 scores and psychological distress scores (K10) was not statistically significantly different between completers and non-completers over time. There was no significant difference between completers and non-completers on socio-demographics, self-reported drug addiction or risk taking behaviour on program entry, except for suicidal thoughts while intoxicated (p = 0.033). Completers were more satisfied with their relationships (p = 0.044) and living place (p = 0.040) on program entry.

CONCLUSION

Overall, completers and non-completers demonstrated improved mental health and quality of life from entry to exit, regardless of program completion. Depression, anxiety and stress reduced more markedly in program completers. Policy makers and programmers could use these findings to further validate their own programs to improve mental health and quality of life of opioid users.

"I just feel comfortable out here, there's something about the place": staff and client perceptions of a remote Australian Aboriginal drug and alcohol rehabilitation service

BACKGROUND

The need for effective, culturally safe residential rehabilitation services for Aboriginal people is widely acknowledged, however the combination of treatment components that is optimally effective, is not well defined. Most existing Aboriginal residential rehabilitation research has focused on describing client characteristics, and largely ignored the impact of treatment and service factors, such as the nature and quality of therapeutic components and relationships with staff.

METHODS

This qualitative study was undertaken as part of a three-year mixed methods community-based participatory research (CBPR) project that aimed to empirically describe a remote Aboriginal drug and alcohol rehabilitation service. Researchers utilised purposive sampling to conduct 21 in-depth, semi-structured interviews. The interviews used a 'research yarning' approach, a form of culturally appropriate conversation that is relaxed and narrative-based. The interview transcripts were thematically coded using iterative categorization. The emerging themes were then analysed from an Interpretative Phenomenological Analysis, focusing on how participants' lived experiences before and during their admission to the service shaped their perceptions of the program.

RESULTS

A total of 12 clients (mean age 35 years, SD 9.07, 91% Aboriginal) and 9 staff (2 female, 7 male, mean age 48 years, SD 8.54, 67% Aboriginal) were interviewed. Five themes about specific program components were identified in the interview data: healing through culture and country; emotional safety and relationships; strengthening life skills; improved wellbeing; and perceived areas for improvement. This research found that Aboriginal drug and alcohol residential rehabilitation is not just about length of time in treatment, but also about the culture, activities and relationships that are part of the treatment process.

CONCLUSION

This study highlights that cultural elements were highly valued by both clients and staff of a remote Aboriginal residential rehabilitation service, with the country or location being fundamental to the daily practice of, and access to, culture. Developing reliable and valid assessments of the program components of culture and treatment alliance would be valuable, given this study has reinforced their perceived importance in achieving positive treatment outcomes. Further, strengthening the aftercare program, as part of an integrated model of care, would likely provide greater support to clients after discharge.