The relationship between the Dimensions of Change Instrument and retention in therapeutic community treatment: the moderating influence of time in treatment.

OBJECTIVES: The Dimensions of Change Instrument (DCI) (1) assesses aspects of the therapeutic community treatment process. More positive scores on two of the eight dimensions of treatment process assessed at the beginning of treatment, Clarity and Safety, and Resident Support, Sharing and Enthusiasm predict retention in treatment at 30, 90, 180, and 270 days as well as overall length of stay. This study explored whether these process subscales assessed at different phases predicted retention at the next phase, and of treatment. METHODS: Five-hundred nineteen individuals, aged 18 to 62, undergoing therapeutic community treatment completed the DCI at baseline, one, three, six, and nine months of the therapeutic community treatment. RESULTS: DCI scale scores at each stage of treatment predicted dropout in the subsequent period. In the early stages of treatment, higher scores predicted a higher probability of retention in the subsequent stage of treatment. In later stages, lower DCI scores predicted a higher probability of retention. CONCLUSIONS: We conclude that predictions about retention made using the DCI scale scores are treatment stage dependent--the DCI predicts retention at the next stage but the direction of the scale prediction varies as a function of client tenure in treatment. This suggests that treatment processes that influence clients to remain early in treatment may change their valence for clients more advanced in treatment.

Treatment process in the therapeutic community: associations with retention and outcomes among adolescent residential clients.

This study examined associations of a new multidimensional measure of therapeutic community (TC) treatment process, the Dimensions of Change Instrument (DCI), with treatment retention (n = 397) and posttreatment outcomes (n = 207) among adolescent residential clients. Adolescents who increased during the first 30 days in treatment on three of the eight DCI factors (Positive Self-Attitude and Commitment to Abstinence; Problem Recognition; Social Network) were more likely to stay in treatment for 90 days or more. Although change in DCI factor scores was not directly predictive of posttreatment outcomes, staying in treatment for 90 days or more increased the likelihood of attending 12-step meetings and having a 12-step sponsor after leaving treatment. Several demographic and pretreatment characteristics also predicted retention, posttreatment outcomes, or both. Much remains to be learned about how the TC treatment process produces positive outcomes for adolescents; however, results from this study highlight components of the treatment process that may be particularly important for practitioners to consider and monitor in their clients.

The dimensions of change in therapeutic community treatment instrument.

In this article, the authors describe the refinement and preliminary evaluation of the Dimensions of Change in Therapeutic Community Treatment Instrument (DCI), a measure of treatment process. In Study 1, a 99-item DCI, administered to a cross-sectional sample of substance abuse clients (N = 990), was shortened to 54 items on the basis of results from confirmatory factor analyses and item response theory invariance tests. In Study 2, confirmatory factor analyses of the 54-item DCI, completed by a longitudinal cohort of 993 clients, established and validated an 8-factor solution across 2 subpopulations (adults and adolescents) and 2 time points (treatment entry and 30-days postentry). The results of the 2 studies are encouraging and support use of the 54-item DCI as a tool to measure treatment process.

Do dimensions of therapeutic community treatment predict retention and outcomes?

First-week Dimensions of Change Instrument (DCI) assessments from a cohort of 519 adults entering six therapeutic communities (TCs) were used to predict treatment retention and outcomes. A more positive first-week response to TC social processes (Community Responsibility; Resident Sharing, Support, and Enthusiasm; Group Process; and Clarity and Safety) and to one TC personal-development process (Positive Self-Attitude and Commitment to Abstinence) predicted retention for the first month. Improvement in Clarity and Safety and Resident Sharing, Support, and Enthusiasm scores at 30 days predicted retention in treatment for 3, 6, and 9 months. In multivariate analyses available to a subset of the entry cohort, a longer tenure in treatment was a robust predictor of posttreatment outcomes. First-week DCI scores on the community process scales predicted posttreatment alcohol-and-other-drug abstinence and functioning.

Are prisoner characteristics associated with therapeutic community treatment process?

The relationship between prisoner client characteristics and Therapeutic Community treatment process was examined in a male program (N = 164) and a female program (N = 195). Analyses were based on client reports on a multidimensional measure of treatment process and administrative data. Prisoner clients who are older or are poly-substance users had better Community Environment scores. Clients with children and fewer lifetime arrests had better scores on Personal Development and Change. Treatment process scores were comparable for clients in the female program and the male program. However, the association of treatment process with client characteristics appears stronger in the male program.

Measuring changes in client-level treatment process in the therapeutic community (TC) with the Dimensions of Change Instrument (DCI).

The Dimensions of Change Instrument (DCI) measures treatment process in residential therapeutic community (TC) settings. It summarizes eight factors of treatment process from a client perspective. We present evidence of the reliability of the DCI for assessing both adult (N = 519) and adolescent (N = 474) client perceptions of treatment process. The DCI factors significantly increase over time, with increases consistently seen across all DCI factors for adults. We highlight areas for future DCI modifications to broaden its applicability to adolescents. Our findings show that clinicians can use the DCI to evaluate adult client progress and target areas for improving quality of care.

How important are client characteristics to understanding treatment process in the therapeutic community?

Prior research has demonstrated that therapeutic communities (TCs) are effective at improving posttreatment outcomes for substance abusers. However, little is known about the in-treatment experience for clients with different backgrounds, experiences, and needs. The aim of this study is to examine the in-treatment experience for different clients by exploring the relationships between treatment process and client characteristics. A comprehensive measure of treatment process, operationalized as Community Environment and Personal Change and Development and change was administered to 447 adults and 148 adolescents receiving treatment at community-based TC programs in New York, California, and Texas. Data on demographic characteristics, substance use and treatment history, and client risk factors were extracted from intake interviews and analyzed separately for adolescent and adult residents. Multivariate general linear models were used to examine the effect of client variables on treatment process, after controlling for treatment duration and program effects. Within adult programs, clients who were 25 years or older, female, and had a prior drug treatment experience had higher Community Environment scores. Adolescents with one or more arrests within the past 2 years had lower scores on both process dimensions of Community Environment and Personal Development and Change. Our results indicate the need to understand why adult clients who are younger, male, and have no prior treatment history and adolescent clients with recent arrests reported lower ratings of treatment process. Future research should also examine the role of modifiable mediators so that appropriate strategies to enhance therapeutic engagement may be developed as necessary.