Role of client early treatment evaluation in post-treatment recovery promoting cognitions and activities

1. Role of client early treatment evaluation in post-treatment recovery promoting cognitions and activities A. Laudet, K. Morgen & V. Stanick National Development and Research Institutes, Inc., J. Carway - VIP Community Services, Inc. NYC, NY B. SandsNYC Health & Hospitals Corp./Woodhull Hospital CenterFunded by National Institutes on Drug Abuse Grant R03 DA13432 Correspondence laudet@ndri.org

2. Background • Participation in addiction treatment has been associated with reduced substance use • Outpatient treatment is the most prevalent treatment modality in the US • The effectiveness of treatment is in part compromised by high attrition rates (dropping out before completion of planned services) • Further, treatment gains are typically short-lived, especially as the intensity and duration of services has decreased • Treatment gains can be maintained by engaging in a set of recovery-promoting behaviors and beliefs such as commitment to abstinence and affiliation with 12-step groups (e.g., Narcotics Anonymous)

3. Background [2] • The early treatment period is particularly critical to engaging clients • Further, there is evidence that patterns established early on in treatment (e.g., 12-step participation) are maintained throughout the treatment period • Therefore it is critical to identify factors that predict the establishment of recovery promoting behaviors • One potentially crucial yet under-investigated domain in treatment engagement and outcome research is clients’ perceptions of/satisfaction with the treatment program, goodness of fit between client and program, and relationship with counselors.

4. Study Objective and Hypothesis • Objective: This study examines the relationship of clients’ early perceptions of treatment and satisfaction to post-treatment outcome domains previously found to be associated with positive recovery outcomes • Hypothesis: More positive treatment evaluation scores predict higher levels of recovery promoting cognitions and behaviors at the end of treatment.

5. Domains under study PREDICTOR DOMAIN (2 weeks after admission): Clients’ treatment evaluation and satisfaction OUTCOME DOMAINS assessed at treatment end: • Treatment completion status • 12-step affiliation (attendance + involvement) • Commitment to abstinence

6. STUDY METHODS • Data collected in the context of a NIDA-funded investigation of predictors and effectiveness of 12-step participation as an aftercare resource. • Participants (total N = 314) recruited from two large inner-city, publicly funded outpatient substance abuse treatment facilities within New York City. • Data gathered at admission to index treatment and treatment end (completion or drop-out). • End of treatment interviews conducted with 237 participants to date (84% of valid cohort – in treatment =<30 days)) • Participation was voluntary and based on informed consent. • Computer-assisted semi-structured interviews approximately 2.5 hours in duration, administered at each data collection point. • Participants received $30 at each interview.

7. Measures PREDICTOR DOMAIN (2 weeks after admission): Clients’ treatment evaluation and satisfaction - We constructed a 7-item Treatment Evaluation Scale assessing satisfaction with program, counselors, treatment plan, etc. (alpha =.74) . Sample domains: expectation if help, counselor/client goal agreement, working as team with counselor, overall satisfaction w.program OUTCOME DOMAINS assessed at treatment end: • Treatment completion status: completion or drop-out • Commitment to abstinence • 12-step affiliation:a • number of AA + NA meetings attended in the past month • Considering oneself a 12-step member • Doing step work a Cloud et al., (2004) What is Alcoholics Anonymous Affiliation? SUBSTANCE USE & MISUSE, Vol. 39, No. 7, pp. 1119–1138.

8. Analytic Plan • Regression analyses were conducted for each of the outcome domains • Linear regressions for continuous outcome domains (number of 12-step meetings and commitment to abstinence) • Logistic regression for categorical outcome variables (treatment end status (complete/drop-out), 12-step member and step work) • The baseline level of the outcome domain was entered in the first step (addiction severity was entered as first step in the regression where treatment end status was the outcome • Early treatment evaluation was entered on the second step

9. DESCRIPTION OF SAMPLE(N = 237) Male 57% Age (mean) 39 years (range = 19-60) African American 62% Hispanic 36% Education (mean): 10.6 years (range = 3-16) Primary income: Government assistance 75(%) Job (on or off the books) 6 Other legitimate income 18 Illegal sources 1 Hepatitis C+ 21% HIV+ 8% Mental Health Problem (ever) 41% Substance Use past month 52% First time in treatment 21%

10. PRIMARY PROBLEM SUBSTANCE @ BL

11. Descriptives of Outcome Domains 1. Treatment Outcomes Length of stay in days (M, SD) 149 (87) Completed 39.2% Drop-out 60.8% 2. Commitment to abstinence (M, SD) b 3.9 (.64) 3. 12-step affiliation (a) Attendance past month (yes) 38.4% # meetings (M, SD) 4.8 (9.3) (b) Involvement 12-step member (yes) 33% Step work (yes) 24% b Possible range = 1 - 5

12. Regression results Early Treatment Evaluation/Satisfaction as predictor B/Beta Wald Sig. OR Treatment completion statusc .67 13.4 .0003 1.95 Commitment to abstinence .14 NA .03 NA 12-step affiliation: Meetings past month .15 NA .02 NA 12-step member d .27 1.8 .18 1.3 Doing step workd .74 8.65. .003 2.1 • ccompletion = 1 • dyes = 1

13. Controlling for baseline level of each of the outcome domains, clients’ early impressions of the program is a significant prospective predictor of recovery-promoting cognitions and behaviors at treatment end: Completing outpatient treatment program Being committed to total abstinence from drugs and alcohol Affiliating with 12-step fellowships: Attending more 12-step meetings Considering oneself a member of a 12-step fellowship CONCLUSIONS

14. Clinical Implications “First impressions” appear to have a lasting and significant influence on addiction treatment outcome, at least in the short-term (i.e., at discharge) This finding can be utilized in the clinical setting to enhance the likelihood of positive outcomes: • Need to recognise that client form impressions about the program very early on • These early impressions may in part, determine the ultimate outcome of the treatment episode • Need to establish ongoing dialogue with client upon admission about treatment expectations, perceptions and needs • Need ongoing assessment of these impressions throughout the treatment episode • Need willingness to adapt critical aspects of treatment (e.g., goals, treatment team) to enhance the fit between client needs and expectations on the one hand, and the services provided on the other hand • Need to address and redress any client inaccurate or misguided expectations about the program as early as possible so that expectations are realistic (e.g., estimated length of needed services, areas where program may and may not be helpful)

15. Research Implications To date, researchers have underestimated the importance of clients’ early perceptions of treatment and their potential influence on subsequent clinical outcome • Need to determine whether the significant influence of clients’ early treatment impressions on clinical outcome endure beyond the end of treatment (e.g., one year later) • Need to identify specific factors that determine clients’ early impressions of treatment (e.g., prior exposure to treatment) • Need to consider staff attitudes/appraisals/expectations of clients, possible interactions with client treatment perception variables, and the possible role of that interaction on treatment outcomes