Relationships between counseling rapport and drug abuse treatment outcomes.

OBJECTIVE: This study examined the association between counseling rapport and drug abuse treatment outcomes. METHODS: Two cohorts of outpatients who were being treated with methadone in four cities were studied. Cohort 1 comprised 354 patients in community-based nonprofit programs, and cohort 2 comprised 223 patients from a private for-profit program. Logistic regression analyses were used to assess the importance of counseling rapport as a predictor of drug use and criminality relative to treatment retention in the index treatment, satisfaction with treatment, and whether additional treatment was received after the index treatment. RESULTS: In both cohorts, ratings made by counselors, during treatment, of therapeutic involvement and relationships with patients provided a useful measure of counseling rapport. A lower level of rapport during treatment predicted worse post-index treatment outcomes, including more cocaine use and criminality, both by itself and after adjustment for treatment retention, satisfaction with treatment, and post-index treatment status. Counseling strategies were associated with the development of counseling rapport. CONCLUSIONS: Counseling rapport is a vital part of the therapeutic process and helps explain why and when treatment is effective. It contributes explicitly to the prediction of outcomes, apart from treatment retention, and accounts in part for the usual association between treatment retention and outcomes.

Importance of identifying cocaine and alcohol dependent methadone clients.

Clients in outpatient methadone treatment (OMT) who abuse cocaine or alcohol are difficult to engage and retain in treatment. The impact a triple addiction to these drugs has on treatment was the focus of this study (N = 127). Admission characteristics, treatment response, and retention were compared among clients dependent on opiates only (O), opiates and alcohol (OA), opiates and cocaine (OC), or all three drugs (OAC). Findings indicate these groups differ in admission needs assessment, session attendance, issues discussed during treatment, and development of counselor rapport, with the OAC group being significantly more difficult to engage and retain in treatment.

Services provided during methadone treatment. A gender comparison.

Greater improvement in posttreatment outcomes has been shown in programs that tailor frequency and type of services to unique client needs. Using a sample of 635 clients (199 females and 436 males) admitted to three community-based methadone treatment programs, this study examined gender differences in services needed and provided during the first 3 months of treatment. Results revealed that compared to males, women entered treatment with more psychological symptoms and AIDS/HIV-risky behaviors; they also presented with less criminal activity, less alcohol use, and higher motivation. Counselors addressed psychological and crisis issues more frequently with women, and counseling strategies were more often directed toward developing problem-solving and communication skills. Counselors also made more medical referrals and reported having better rapport with females. Attention to employment issues and HIV/AIDS sexual-risk behaviors did not differ by gender, even though women had more needs in these areas.

Contingency management in outpatient methadone treatment: a meta-analysis.

A meta-analysis was conducted on contingency management interventions in outpatient methadone treatment settings. The outcome measure of interest was drug use during treatment, as detected through urinalysis. The results confirm that contingency management is effective in reducing supplemental drug use for these patients. The analysis of behavioral interventions yielded an overall effect size (r) of 0.25 based on 30 studies. Significant moderators of outcomes included type of reinforcement provided, time to reinforcement delivery, the drug targeted for behavioral change, number of urine specimens collected per week, and type of subject assignment. These factors represent important considerations for reducing drug use during treatment.

Modeling year 1 outcomes with treatment process and post-treatment social influences.

Follow-up studies of drug user treatment generally find significant improvements in client functioning, but information about the therapeutic components associated with client behavioral changes over time is limited. An integrative model developed previously to predict treatment retention was expanded and applied to post-treatment outcomes. This study is based on 321 daily opioid users treated in three methadone treatment clinics. Effects of pre-treatment motivation, treatment process measures representing therapeutic relationship, counseling session attendance, and length of treatment are examined in relation to measures of family relations, peer deviancy, return to treatment, drug use, and criminality in the year after treatment. Models were tested in two stages. The first was built on a during-treatment process model for predicting time in treatment to include post-treatment outcomes. The second model was expanded further to include the effects of intervening social support variables as predictors of post-treatment drug and criminality outcomes. The results supported both models and emphasize the importance of considering social influences and related community contextual factors that affect recovery dynamics.

Integrative modeling of client engagement and outcomes during the first 6 months of methadone treatment.

Integrative models containing client and treatment components were tested in a sample of 396 daily opioid users from three methadone maintenance treatment sites. Measures included client motivation at intake as well as repeated assessments of therapeutic engagement (relationships between clients and their counselors, session attendance, and results of urine testing) during the first 6 months of treatment. There was a positive effect of pretreatment motivation on greater engagement and a reciprocal positive relationship between components of engagement and their effects on lowering drug use throughout treatment. Further analyses addressed differential effects of group versus individual counseling and showed that group session attendance was associated with higher rates of drug-negative urines.

Gender differences at admission and follow-up in a sample of methadone maintenance clients.

Although one-third of clients enrolled in methadone treatment in the United States are female, few studies have looked at gender differences at admission and follow-up. Using interview data from 435 clients (31% female) collected at admission and approximately 1 year after discharge, females were found to have more dysfunctional families of origin and greater prior and current psychological and medical problems. Both genders improved following treatment, as evidenced by reduced illicit drug, tobacco, and alcohol use, criminal involvement, and HIV/AIDS-risky behaviors. Females were more likely to seek further help for both drug misuse and psychological problems subsequent to discharge.

Drug abuse treatment retention and process effects on follow-up outcomes.

After finding that retention in methadone treatment for a year or longer was a highly significant predictor of patient outcomes following discharge, measures of pretreatment motivation and early therapeutic engagement were examined as predictors of program retention. Personal interviews were conducted with a sample of 435 patients 12 months after discharge from three methadone treatment programs. Logistic regression results showed several patient attributes--i.e. over 35, lower injection frequency before admission, and higher motivation for treatment--were each associated with twofold increases in the likelihood of having favorable follow-up outcomes on illicit drug use, alcohol use, and criminal involvement. Patients staying in treatment a year or longer, however, were nearly five times more likely to have better outcomes. Further analyses established that length of treatment stay was predicted by higher patient motivation at intake and early program involvement. The findings suggest that more comprehensive models of patient attributes, therapeutic process, and environmental influences are needed, and that treatment enhancement efforts should focus on such during-treatment measures as interim criteria for improving posttreatment outcomes.

Heavy drinking, alcohol-dependent vs. nondependent methadone-maintenance clients: a follow-up study.

This study of methadone-maintenance clients interviewed approximately 1 year after discharge from treatment revealed that outcomes differed between heavy-drinking clients who are alcohol dependent and those who are not. Alcohol-dependent clients seem to benefit more from treatment but continue to have severe cocaine-use problems, suggesting they also may be cocaine dependent. The results emphasized the value in differentiating between these types of drinking clients, and they suggest that failure to do so may account for earlier contradictory results about the role alcohol consumption has in treatment outcomes for methadone-maintenance clients.

Drug abuse treatment process components that improve retention.

BACKGROUND: Longer retention has been the most consistent predictor of favorable drug abuse treatment outcomes, but key therapeutic and patient engagement indicators of treatment process need to be more clearly established. METHODS: An integrative model representing treatment dynamics was tested for explaining long-term program retention. It was based on a multisite sample of 527 daily opioid users who remained in methadone maintenance a minimum of 3 months. All had been assigned randomly to a counseling condition at admission (i.e., cognitively enhanced or standard), and information obtained from patient files, as well as periodic assessments completed by patients and their counselors in the first 90 days after admission were the sources of predictors. RESULTS: Counseling enhancements (using node-link mapping, a visual representation tool for improving communication and problem solving) contributed to stronger therapeutic relationships between counselor and patient, which in turn had a positive reciprocal relationship with patient engagement (session attendance). Pretreatment motivation measured at intake was also related to higher engagement. More positive therapeutic relationships (in months 1 and 2) led to lower levels of during-treatment drug use (defined from urinalysis results in months 2 and 3), and better session attendance and therapeutic relationships both predicted longer retention. In addition, lower drug use during treatment was related to longer retention. CONCLUSIONS: Major conceptual domains of drug abuse treatment process were identified in community-based programs and their interrelationships with retention specified. As intermediate (during treatment) criteria, they can help guide functional improvements in program effectiveness as illustrated with our counseling enhancements.

Effectiveness of a specialized women's intervention in a residential treatment program.

"Time Out! For Me," a specialized psychoeducational treatment found to be effective with women in an outpatient methadone clinic, was tested for generalizability to a residential drug user treatment program. The 6-session module was first given to an experimental group (n = 11) and compared to a control group (n = 10). The treatment was associated with increases in knowledge of human sexuality, assertiveness and communication skills, more positive attitudes toward being assertive and practicing safer sex, and increased self-esteem. Thus, "Time Out" appears to be an effective treatment enhancement for women in residential treatment.

Heavy drinking in a population of methadone-maintained clients.

OBJECTIVE: The purpose of this study was to clarify the relationship between heavy use of alcohol and response to methadone treatment. METHOD: A sample of clients showing three or more DSM-III-R symptoms (n = 79) were identified and compared with a sample of heavy-drinking clients (n = 108) with less than three alcohol dependency symptoms on admitting characteristics and on tenure in treatment. RESULTS: As expected, clients meeting DSM-III-R dependency criteria were significantly more likely to show evidence of psychological problems and dysfunction of family and peer relations at admission. An unexpected finding was that they were also more likely to remain in treatment longer than drinking clients who did not report dependency. Alcohol dependent clients were significantly more likely to have prior experience with self-help groups, which may reflect less denial and therefore relatively better ability to focus on opiate dependency problems. CONCLUSIONS: Failure to differentiate between alcohol dependent and nondependent groups of drinkers enrolled in methadone treatment may help account for reported differences in treatment outcome studies. Recognizing these different types of drinkers also may help clinicians plan more effective treatments.

Effectiveness of a specialized intervention for women in a methadone program.

Over the past 20 years, specialized programming for chemically dependent women has been recommended for improving psychosocial functioning and retention in treatment. This study examined the impact of a structured, six-week assertiveness and sexuality workshop for women at three community-based methadone maintenance programs. Results indicated that women who participated frequently in the women's groups (four to six sessions) showed greater increases in self-esteem and knowledge compared to women who participated infrequently (one to three sessions). In addition, level of participation was positively associated with length of stay in the treatment program after completing the workshop.