|
Addiction counselors always seem eager to know what client variables predict treatment outcome, and that is the focus of this column.
Treatment prediction variables are a set of factors (internal or external) that explain how clients associated with these variables will do in treatment. It is important to note that these variables only predict or forecast an outcome. They are not, in and of themselves, the cause of a treatment outcome, but can identify client groups who have alleged poor factors. Once identified, these clients can be targeted for special treatment so they don’t fall through the cracks. To gain some perspective on prediction variables, we will review some past attempts to find predictive patterns of treatment outcome, followed by a look at a recent systematic piece of research (Adamson, Sellman & Frampton, 2009) that examines 30 years of prediction research, to see what new patterns have emerged. Around 1977, a meta-analysis of 45 studies, completed by Gibbs and Flanagan, found a few stable predictors of better treatment outcome, including: a steady work history; low psychopathology; a history of fewer arrests; and a history of Alcoholics Anonymous (AA) attendance. About 20 years later, Brewer, Catalano, Haggerty, Gainey and Fleming (1998) identified a number of predictors of future drug use, including: high levels of drug use before entering treatment (in this case, opioids); associated depression; higher levels of stress; employment problems; socializing with substance abusing peers; and leaving treatment before completing the program. Just a few years later, McKay and Weis (2001), in a similar analysis, found pretreatment levels of substance use and psychiatric severity were
predictive of poorer outcomes, while stronger motivation and better progress in treatment generally indicated better treatment outcomes.
While informative, these past findings are dated; therefore, more recent research and stricter statistical analysis was needed to assess the current state of predictive treatment outcome variables. By following a rigid set of statistical guidelines and reviewing more than 60 research papers, Adamson, Sellman and Frampton (2009) were able to identify several reliable predictors of treatment outcome, including:
• Self-efficacy, or a belief in one’s confidence to do well in treatment. The most consistent predictor found, this basically translates to the more confidence a client has in the recovery process, the better he or she does.
• Motivation, or the level of inspiration or enthusiasm the client
has toward recovery. The more motivated a client is, the better the treatment outcome.
• Treatment goal, or achieving specified recovery plans goals within the span of treatment. Those who achieved their recovery goals did better.
• Dependence severity, or the more severe the substance dependence, in terms of duration and intensity, the poorer the treatment outcome.
• Psychopathology ratings, or the higher the levels of comorbid psychopathology (e.g., depression, anxiety) the poorer the outcome.
Interestingly, some variables that one might have thought to be important did not make the grade, including: income; gender; religion; co-existing anti-social personality disorder; other personality disorders; the onset of alcohol misuse; a family history of drug or alcohol problems; and associated alcohol related problems (e.g., work, social, health and family). Try it
The Adamson et al. (2009) study provides information that can be easily applied to an existing program.
In terms of the self-efficacy, the counselor’s job is to build confidence so clients can have faith in their ability to complete treatment, and do well in recovery. How do you help someone who comes into your program with a defeatist attitude? How do you help someone gain “I can do this” attitude? Most modern addiction counseling books don’t have much to say about this. Yet, one can achieve overall confidence by first succeeding with small, very manageable steps or goals, which can be used to go after bigger things. A rough illustration of this might be, cutting down one cigarette per day, and using the small dose of confidence to further cut down to two, and so on. The counselor should help the client achieve and maintain change. While there are several studies on the dynamics and course of motivation, there is limited information on actually doing it. The best available instructions are the traditional reinforcement theories that give rewards for good behavior; negative rewards for not so good behavior; and modeling. Sometimes putting things into a moral perspective is useful; convince the client that treatment is the right thing to do. Others respond better to inspiration, such as seeing a fellow client or sponsor do well and aspiring to do the same. The counselor’s job is to get creative and come up with things that motivate the individual client. Treatment goals should be easily achievable so that clients are more likely to reach them. In turn, an achievement would generally elicit motivation. Regarding dependence severity and psychopathology levels, a good clinical intervention should pay close attention to these folks upon admission by: providing them with more counseling time; building a stronger rapport; and watching for craving spikes, as well as spikes in depression or psychotic symptoms. It is important to create a plan to offset these depressive or psychotic episodes by determining how the client made it through past spikes, and use that in the treatment plan. For example, I worked with a client who had paranoia elevations on the weekends that would land him in the local hospital emergency department. We tried a number of different things that didn’t work. Then we started to pay attention to the weekends when he had diminished levels of paranoia. We discovered that he had simply gone to the beach to talk with his friends, and entertained pleasant thoughts of his daughter. By encouraging him to use just these two behaviors, he was able to get through weekends without going to the emergency department. It helped his self-efficacy as well. Research you can do
For our purposes, you can do a quick and dirty pre/post test by comparing your past program outcome results to doing treatment just a bit differently, using some of the information provided by the Adamson et al (2009) study. Encourage the staff, or yourself, to place more emphasis on the five main findings listed above. For instance, place more effort on a current sample of clients to raise self-efficacy. Then three and six months after that sample has left treatment, measure how well they did on say total abstinence days, hospital visits, arrests, etc. Compare those results to a matched past sample from your program. As always, I remain interested in your findings.
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
Adamson, S.J., Sellman, J.D., & Frampton, C.M.A. (2009). Patient predictors of alcohol treatment outcome: A systematic review. Journal of Substance Abuse Treatment, 36, 75–86
Brewer, D.D., Catalano, R.F., Haggerty, K., Gainey, R.R., & Fleming, C.B. (1998). A meta-analysis of predictors of continued drug use during and after treatment for opiate addiction. Addiction, 93, 73–92
McKay, J.R. & Weis, R.V. (2001). A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-up. Evaluation Review, 25, 113–161.
|
