The efficacy of role induction in preventing early dropout from outpatient treatment of drug dependency

Exploring treatment attendance and its relationship to outcome in a randomized controlled trial of treatment for alcohol problems: secondary analysis of the UK Alcohol Treatment Trial (UKATT)

AIMS

To identify client characteristics that predict attendance at treatment sessions and to investigate the effect of attendance on outcomes using data from the UK Alcohol Treatment Trial.

METHODS

Logistic regression was used to determine whether there were characteristics that could predict attendance and then continuation in treatment. Linear regression was used to explore the effects of treatment attendance on outcomes.

RESULTS

There were significant positive relationships between treatment attendance and outcomes at Month 3. At Month 12, these relationships were only significant for dependence and alcohol problems for those randomized to motivational enhancement therapy (MET). There were significant differences between groups in attendance, with MET clients more likely to attend than clients allocated to social behaviour and network therapy (SBNT). MET clients were also more likely to attend all sessions (three sessions) compared with SBNT (eight sessions). MET clients with larger social networks and those with confidence in their ability not to drink excessively were more likely to attend. SBNT clients with greater motivation to change and those with more negative short-term alcohol outcome expectancies were more likely to attend. No significant predictors were found for retention in treatment for MET. For those receiving SBNT, fewer alcohol problems were associated with continuation in treatment.

CONCLUSION

Attending more sessions was associated with better outcomes. An interpretation of these findings is that, to improve outcomes, methods should be developed and used to increase attendance rates. Different characteristics were identified that predicted attendance and continuation in treatment for MET and SBNT.

Vocal hygiene education, voice production therapy, and the role of patient adherence: a treatment effectiveness study in women with phonotrauma

PURPOSE

To assess the effectiveness of vocal hygiene education (VHE) and voice production therapy (VP) in altering patient perception of vocal handicap in adult women with benign, bilateral phonotraumatic vocal fold lesions and the role of adherence in that perception.

METHOD

Sixty-two women were randomly assigned to 6 weeks of VP (n = 31) or VHE (n = 31), followed by 4 weeks of self-study. The primary outcome measure was the Voice Handicap Index (VHI) score, assessed at baseline, post-therapy, and post-self-study. Patient adherence was assessed as a cofactor.

RESULTS

Both groups achieved a decrease in VHI scores from baseline to completion of the study, although the improvement was significantly greater for the VP group. The treatment effect size was large for the VP group and small for the VHE group. More participants adhered to VP than to VHE. Only adherent participants achieved significant improvement. Only adherent participants in the VP group improved with self-study. More than two thirds of the VP group achieved final VHI scores within normal limits, compared with approximately one third of those in the VHE group.

CONCLUSIONS

VP therapy may be more effective than VHE in addressing patient perception of vocal handicap in adult women with phonotrauma, and self-study may be an important component of therapy. However, adherence is a critical mediator of outcome.

Illusory predictors: Generalizability of findings in cocaine treatment retention research

Treatment retention is of paramount importance in cocaine treatment research as treatment completion rates are often 50% or less. Failure to retain cocaine patients in treatment has both significant research and clinical implications. In this paper we qualitatively and quantitatively demonstrate the inconsistency found across analyses of retention predictors in order to highlight the problem. First, a qualitative review of the published literature was undertaken to identify the frequency of predictors studied and their relations to treatment retention. Second, an empirical demonstration of predictor stability was conducted by testing a common set of variables across three similar 12-week cocaine clinical trials conducted by the same investigators in the same research clinic within a five-year period. Results of the literature review indicated inconsistently selected variables of convenience, widely varying statistical procedures, and discrepant findings of significance. Further, quantitative analyses resulted in discrepancies in variables identified as significant predictors of retention among the three studies. Potential sources of heterogeneity affecting the consistency of findings across studies and recommendations to improve the validity and generalizability of predictor findings in future studies are proposed.

Impact of Role Induction on Long-Term Drug Treatment Outcomes

In prior research, Katz et al. found that role induction (RI) improved engagement for substance dependent clients relative to standard outpatient treatment orientation. The current study replicates and extends these findings to an examination of long-term outcomes. Substance dependent clients entering outpatient drug-free treatment (N = 353) were randomly assigned to RI or to Standard (ST) orientation followed by routine clinic treatment. Measures of employment, crime, and substance use were collected at intake and at six- and 12-months post-intake. Controlling for baseline differences in substance use, results partially replicated our earlier findings of better engagement for RI, as compared to ST participants; more RI than ST participants attended at least one post-orientation counselling session. RI improved 12-month substance use outcome relative to ST. The potential gain in retention and in reduced substance use at follow-up associated with a single RI session, recommend this strategy for further development and study.

African-American crack abusers and drug treatment initiation: barriers and effects of a pretreatment intervention

BACKGROUND

Individual and sociocultural factors may pose significant barriers for drug abusers seeking treatment, particularly for African-American crack cocaine abusers. However, there is evidence that pretreatment interventions may reduce treatment initiation barriers. This study examined the effects of a pretreatment intervention designed to enhance treatment motivation, decrease crack use, and prepare crack abusers for treatment entry.

METHODS

Using street outreach, 443 African-American crack users were recruited in North Carolina and randomly assigned to either the pretreatment intervention or control group.

RESULTS

At 3-month follow-up, both groups significantly reduced their crack use but the intervention group participants were more likely to have initiated treatment.

CONCLUSION

The intervention helped motivate change but structural barriers to treatment remained keeping actual admissions low. Policy makers may be interested in these pretreatment sites as an alternative to treatment for short term outcomes.

How does dialectical behavior therapy facilitate treatment retention among individuals with comorbid borderline personality disorder and substance use disorders?

For individuals presenting with comorbid borderline personality disorder (BPD) and substance use disorders (SUD), rates of treatment dropout from combined mental health and substance abuse treatment centers approach 80%, rendering dropout the rule rather than the exception. Several studies indicate that utilizing a more comprehensive treatment such as Dialectical Behavior Therapy (DBT) may be useful for client retention; however, given the scope and effort required to conduct this treatment, it may be more practical to determine which specific components within DBT are useful in retaining clients in substance use treatment. Thus, the purpose of the current paper is first to determine what exact deficits underlie treatment dropout among the BPD-SUD comorbidity. Second, we review and evaluate effectiveness of DBT retention-enhancing strategies by assembling work from other samples and literatures that also tests retention-enhancing strategies discussed in DBT. As a last step, the paper will conclude with a discussion on methodological limitations and potential future directions in this line of research.

Facilitating behavioral change in voice therapy: the relevance of motivational interviewing

PURPOSE

The purpose of this article is to present an exploration of some of the issues surrounding adherence to vocal behavioral change in voice therapy within the context of Motivational Interviewing (MI) and to explore MI's potential for integration into voice therapy (MI-adapted voice therapy). MI is a style of interpersonal communication in which resistance is minimized through the use of skillful listening in a directive, constructive discussion about behavior change. The goal of MI-adapted voice therapy is to enhance patient adherence to vocal behavioral change.

METHOD

A narrative review of the literature is presented, together with the experiences of the author with 10 adult patients with voice disorders who participated in MI-adapted voice therapy.

RESULTS

It is shown that the principles of MI can be applied throughout the therapy program. Points of resistance to vocal behavioral change that were common across many patients appeared to be addressed appropriately by specific MI dialogue strategies.

CONCLUSIONS

It is concluded that MI-adapted voice therapy holds promise as an approach to address patient adherence to vocal behavioral change. However, research is necessary to define the efficacy of this approach and the factors associated with its efficacy.

Preparing clients for alcoholism treatment: effects on treatment participation and outcomes

In this study, 126 clients (87 men, 39 women) entering outpatient alcoholism treatment were assigned randomly to 1 of 3 preparatory conditions: a role induction (RI) session, a motivational interview (MI) session, or a no-preparatory session control group (CG). Clients assigned to the MI preparatory condition attended more treatment sessions and had fewer heavy drinking days during and 12 months after treatment relative to CG clients. Clients assigned to MI, relative to CG clients, also had more abstinent days during treatment and during the first 3 months posttreatment, although this difference was not maintained through the remainder of the 12-month follow-up period. Clients assigned to the RI condition showed no significant advantage over those in the CG condition.

Strategies for preparing clients for treatment. A review

Substantial numbers of mental health clients do not return following their initial therapy visits or drop out of treatment prematurely. Two general classes of strategies designed to reduce premature attrition and enhance treatment participation are reviewed. Research on psychotherapy preparatory techniques (role induction, vicarious therapy pretraining, and experiential pretraining) indicates that these educational techniques are effective in reducing early treatment attrition and may be especially effective with populations at high risk for dropout (e.g., lower socioeconomic groups, chronically mentally ill clients, and institutionalized juvenile delinquents). Motivational interviewing, a technique originally developed for clients with alcohol problems, is designed to reduce client ambivalence toward therapy and change and enhance commitment to and motivation for treatment. Research in the alcohol field suggests that a session of pretreatment motivational interviewing enhances treatment outcome. Both motivational interviewing and psychotherapy preparatory techniques are relatively brief and easy to incorporate into existing mental health care.

Predicting postprimary treatment services and drug use outcome: a multivariate analysis

The substance abuse treatment field is continually challenged to develop interventions that encourage drug abusers to remain longer in therapeutic services and that facilitate improved outcomes. As one of those interventions, case management has generally not been subjected to multivariate analysis to evaluate its role in accomplishing those goals. Using a sample of 444 veterans who received substance abuse treatment services, this study examines relationships among demographic and psychosocial variables at intake, assignment to either traditional or enhanced (case management) treatment services, and both proximal (postprimary treatment contact) and distal (severity of drug use) measures of outcome. Multivariate analyses reveal that case-managed clients stay longer in postprimary treatment services than non-case-managed clients, and consequently, longer postprimary treatment contact leads to better drug use outcomes. The implications of these findings are discussed.

The effect of an orientation-to-treatment group on the retention of alcoholics in outpatient treatment

Seventy-five poor inner city alcoholics were exposed to a 1/2-hour videotape orienting them to treatment. When compared to a similar group that did not see the videotape, the orientation group attended more clinic sessions in the following month. A greater percentage of them made more than 10 visits, were still active after the month, and went on to inpatient rehabilitation. The orientation group is an effective, cost efficient way of increasing patient follow through with treatment.

Enhancing Criminal Justice Based Treatment through the Application of the Intervention Approach

The innovative, successful and widely replicated Weekend Intervention Program (WIP) has been highly effective in identifying and intervening with persons charged with alcohol (and other drug) related driving offenses. WIP's model approach allows a high degree of specificity in assigning individuals to the most appropriate treatment setting and successfully prepares the offender for the substance abuse services to be received, therefore, addressing a major impediment to successful treatment — early drop out. Expanded utilization of a program such as WIP can greatly enhance the therapeutic and cost effectiveness of criminal justice system treatment efforts and help establish a viable productive partnership between the criminal justice system and the substance abuse treatment community. In this article the authors describe WIP, its clinical approach and evaluation, and comment upon the benefits of its wider use.

Adolescent chemical use and dependence: current issues in epidemiology, treatment and prevention

This review provides a pragmatic and clinical orientation to current issues in adolescent chemical dependence in addition to exploring legitimate and relevant unanswered questions about chemical dependence. The lack of research on adolescent chemical dependence is addressed in light of the updated epidemiology. Patterns of use, abuse and dependence among adolescents are reviewed. The article examines treatment issues as well as prevention strategies among children and adolescents. Future clinically oriented research directions are suggested to promote further investigation into these areas.

Differences in organization of psychological needs between inpatient and outpatient opiate addicts

A total of 117 inpatients and 114 outpatient drug addicts were administered the Adjective Check List; protocols were subjected to a hierarchical cluster analysis. Results showed two basic clusters for inpatients and one large cluster in the outpatient sample, each different in personality need organization. At discharge, patients who moved from Clusters I or II (inpatient) to Cluster III (outpatient) continued with outpatient treatment. None of the "independent" patients pursued outpatient treatment, while patients in the "emotionally dependent" cluster who pursued outpatient treatment eventually were placed on methadone maintenance. Results suggest that drug addicts who request inpatient or outpatient treatment may be a self-selected sample who differ in personality organization, which, in turn, may predict treatment follow-up in an aftercare setting.

Differences in psychological need hierarchy between program completers and dropouts from a drug abuse treatment program

Psychological need patterns among 116 drug addicts in treatment were measured with the Adjective Checklist. Compared to program completers, program dropouts had higher needs for autonomy and aggression and lower needs for deference, nurturance, and affiliation. This personality style may form the basis of dropping out, among certain types of addicts in certain types of programs, when faced with situational, environmental, or interactional stress. Results also suggest that we may be able to identify a personality pattern at risk for premature termination before the person experiences the impulse to leave.

Can personality tests predict treatment dropouts?

Patients who completed a detoxification/rehabilitation drug abuse program were compared with program dropouts on a new personality instrument, the Millon Clinical Multiaxial Inventory. No differences were found between groups on any of the 20 comparison variables, replicating previous results with the MMPI. Data are presented showing that discriminant function predictors lose their potency within 3 years and maybe sooner. It is concluded that clinical judgments must form the basis of predicting dropouts until it can be demonstrated that personality tests can make reliable predictions on treatment dropouts.

Personality dimensions related to premature termination from an inpatient drug abuse treatment program

Comparison of 135 program completers and 65 dropouts from an inpatient drug abuse detox/rehab. unit on 29 variables (MMPI validity and clinical scales, 13 Wiggins Content Items, number of Grayson Critical Items selected, MacAndrews Alcoholism Scale, and Age) revealed few group differences with univariate analyses. Multivariate and stepwise discriminant function analyses resulted in selected variables that achieved 64-87% stay/leave classification accuracy, depending on method of application. However, when these functions were cross-validated on independent samples within the same program at 3-year intervals, the classification accuracy generally was reduced by 50% or more. Results suggest that (a) there are few individual MMPI indices that predict patients at risk for program attrition; and (b) "good" multiple regression equations may not generalize to independent samples across time. Conceptualizing the dropout process ontogenetically will facilitate further experimental refinement and clinical understanding.

Reducing attrition from conjoint therapy with alcoholic couples

Premature termination of treatment by the client has been a pervasive problem in the alcohol treatment field. This drop-out problem is compounded in conjoint therapy for alcoholic couples since most clients typically do not view the drinking problem from a systemic, interactional perspective. Within a short-term communication-interaction based conjoint therapy program offered to couples with an alcohol problem on an outpatient basis, specific mechanisms were developed to deal with client-initiated attrition from treatment. These procedures involve the systematic involvement of the spouse in all aspects of intake, assessment and treatment; the use of role induction in a pretherapy interview; and formal contracting during the beginning phase of therapy. Preliminary results suggest that these efforts may be effective in retaining more socially stable alcoholic clients. For the more transient, less socially stable group of individuals with alcohol-related difficulties, the above mechanisms may not be sufficient to forestall unplanned terminations. It is suggested that the latter group may require help to reduce stresses related to concrete concerns prior to receiving conjoint therapy for their alcohol problem.