If you noticed, this column is entitled “Research to Practice.” Its job has been to bring solid research findings to the addiction professional without all the technical jargon of peer-reviewed articles. But this time, I want to put the emphasis of this particular column on the “research” part of its title. Rather than summarize a piece of research into something practical, we are going to try to explain an important element in research and then apply that to your clinical practice.

Of all the research that is published in our field, I find the summary analysis to be the most stimulating. That is the one where a researcher examines tons of past good research literature, then filters out some golden nuggets.

New Zealand’s Douglas Sellman, MB, ChB, PhD (Otago), FRANZCP, FAChAM, who has been working in the addiction treatment field since 1985 and serves as Director of the National Addiction Centre, Christchurch School of Medicine & Health Sciences since its inception in 1996 and is a professor at University of Otago since 2006, did just that for the addiction field. He reviewed addiction literature that spanned 40 years. From all that research, he surmised that there are ten things every clinical professional should know about this thing called addiction. These “things” are key points to understand about addiction behavior and include some elements of addiction treatment. They are broad based, and as such, do not lend themselves well to specific practical applications. Instead, consider them as large directional beacons. Follow them and they may guide you well.

There has always been link between the spiritual/religious and alcohol abuse. This connection extends to religious efforts of centuries past and present to assuage drinking. Given that connection, one would have thought rigorous research that associates prayer and alcohol use would have been studied with relish. It hasn’t. But, occasionally a piece of research comes along that tries to fill that void. That’s the focus for this column.

Previous Prayer Research

Most of the research on prayer and alcohol use is of the non-experimental variety, with most studies consisting of surveys and the quasi-experimental designs (where complete control over the variable is not in place and the results’ causal conclusions cannot be drawn). As an example, a meta-analysis found that unlawful behavior and religiosity were negatively correlated; simply, the stronger one’s religion the lower his or her unlawful behavior (Baier & Wright, 2001). A number of surveys found higher levels of spirituality and religion were related to lower alcohol consumption (Benda et al., 2006; Johnson, et al., 2008). Practices of private prayer were related to lower risk of alcohol use disorders (Koenig et al., 1994). Interestingly, the studies reviewed found that praying for someone did not have the effect of lowering alcohol use.

In Part I of this two-part column, we reviewed some early research on this frustrating problem. In Part II, we address subsequent data that includes substances that are generally associated with dropout; the role of 12 Step groups; and the impact of the professional relationship, among others.

The addiction field has its fair share of frustrations. One that ranks high on that list is client dropout. Call it absent without leave or against medical advice, it troubles, even disturbs, the best addiction counselors. Often, we are at a loss to explain the phenomena, let alone figure out what to do about it. That doesn’t have to be the case.

Over the years a number of dropout studies have been conducted from several programs. The literature addresses dropout for men, women, adolescents and chemical of choice used (e.g., heroin, cannabis), 12 Step groups, and even its relation to the strength of professional rapport. Some of the research specified suggestions to reduce dropout, which is included. Some research did not, but treatment suggestions are inferred from them.

There is a fair amount of information on dropout, so the column is divided into two parts. Part I covers mostly early dropout research, while Part II covers some later and specific studies. This review is by no means exhaustive, but the findings might prove useful in your practice or program.
Early findings n 1985, Craig questioned 75 clients who dropped out of a drug program. The most frequent reason cited by the clients was that they simply felt better. Other reasons cited were personal, financial and household problems.

In 1993, a study of 311 clients from three different outpatient programs found a 24 percent dropout rate. Among the reasons cited, three stood out:
• Those who where maintained on lower doses of methadone (in the programs that offered methadone) tended to drop out, while those maintained on higher doses tended to stay in treatment.
• Those rated with lower motivation tended to drop out, while those with a higher level stayed.
• Those with an unstable background tended to drop out. This background measure was based on employment (not employed), marital status at the time of admission (not married), and a higher number of arrests in the six months prior to their admission. Clients who were employed, married and had no arrests prior to admission stayed in treatment.   

A comparison of these findings to dropout findings of 12 other studies during that same time were comparable, noting that low motivation, low methadone dose, higher criminality and unemployment were related to early termination from addiction treatment.
Dropout studies from therapeutic communities found the only reliable client characteristics that predicted dropout were a high degree of criminality and severe psychopathology (DeLeon, 1994). Those same studies indicated that legal pressure often keeps clients in treatment as does stronger motivation, and a readiness for treatment.

Motivation and a readiness for treatment are both important for clients to remain in treatment (Melnick et al., 1997). However, in their study of over 1,000 adolescent clients, they found that, as a whole, adolescents were less motivated and ready for treatment. The same two factors were shown to be important to adolescents staying in treatment as were the adults.

A study of 235 outpatient clients found that longer wait times from the initial call to set the appointment to the actual scheduled appointment was at the top of the list of reason for missed appointments (Festinger, et al., 1995). Other variables, such as the program’s location, type of substance abused, reported last use of a substance, and the assigned counselor’s gender stood out as reasons for not attending that first session.

Women and dropout
Studies of drop-out have focused on certain populations that may not have received the attention they need. A retrospective study examined 160 women, and found that they generally stayed in treatment if they were employed, had a history of sexual abuse, considered alcohol as their drug of choice, and were older, single and connected with the treatment philosophy to which they were admitted (Copeland & Hall, 2006). Other factors that reduced dropout in­cluded having dependent children in their care, being lesbian and being in a woman’s specialized program.
Without conducting a rigorous statistical examination of the studies listed thus far, the top client drop-out reasons include:
• Low motivation
• Comorbidity
• Higher levels of criminality prior to treatment
• Unemployment following treatment

It is likely that you will see these variables more often than the others. That is not to diminish the other variables, but this should put you on alert for these prominent factors.  

There are no pat answers to working with this population. However, there are general suggestions. First, as is the mantra in addiction treatment these days, you have to individualize your client treatment. Second, these particular variables would indicate that you, as the practitioner, need to become keenly aware of them showing up in your caseload. That means putting a sharper focus on the assessment of these factors. Simply, learn to detect them and don’t allow them to slide below the radar. As to interventions, I wish there were easy answers, but since there are not, consider some other points:
• If a dropout variable is discovered, give it more attention. That generally means spending more time with the client and engaging in a frank, open discussion about the dropout factor.
• A consistently important treatment tip is to gain as strong a professional alliance with the client as you can. Generally, clients respond better to
therapists with whom they can connect and feel understood.
• Consider using motivational interviewing (MI) for the low motivation clients. MI claims to work well with this crowd (Miller & Rollnick, 2002)
• Be creative.
• And, as a cheesy as this sounds—don’t give up.

Mike Taleff has written numerous articles, several books, teaches at the college level, and conducts trainings and workshops (e.g., the latest treatment practices, Critical Thinking and Advanced Ethics). He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References
Bentall, R.P. (2009). Doctoring the mind. New York: New York University Press.
Craig, R.J. (1985). Reducing the treatment drop out rate in drug abuse programs. Journal of Substance Abuse Treatment, 2, 4, 209-219.
Copeland, J. & Hall, W. (2006). A comparison of predictors of treatment drop-out of women seeking drug and alcohol treatment in a specialist women’s and two traditional mixed-sex treatment services. British Journal of Addiction, 87,6, 883-890.
De Leon, G. (1994). Therapeutic communities. In M. Galanter & H.D. Kleber Eds. Textbook of substance abuse treatment. (pp: 391-414). Washington, DC: American Psychatic Press.
Festinger, D.S., Lamb, R.J., Kountz, M.R., Kirby, K.C., & Marlowe, D. (1995). Pretreatment dropout as a function of treatment delay and client variables. Addictive Behaviors, 20, 1, 111-115.
Melnick, G. De Leon, G., Hawke, J., Jainchill, N., & Kressel, D. (1997). Motivation and readiness for therapeutic community treatment among adolescents and adults substance abusers. The American Journal of Drug and Alcohol Abuse, 23, 4, 485-506.
Miller, W.R & Carroll, K.M. (2006). Drawing the science together: Ten principles, ten recommendations. In W.R. Miller & K.M. Carroll (Eds.) Rethinking substance abuse: What the science shows and what we should do about it. (pp:293-311) New York: Guilford.
Miller, W.R. & Rollnick, S. (2002). Motivational interviewing. New York: Guilford.
Simpson, D.D. & Joe, G.W. (1993). Motivation as a predictor of early drop out from drug abuse treatment. Psychotherapy Theory, Research, Practice and Training, 30, 2, 357-368.