Unlike the previous “Research to Practice” columns, this one has no particular theme. In this column, we relay a series of short, but practical counseling suggestions. As usual, they all have an empirical base of support.

Clients who don’t show up for their first appointment have always frustrated counselors. This particular problem is equally applicable to inpatient and outpatient programs. Intake workers, administrative professionals, and counselors take the time and effort to set up an appointment, and what happens — we get a no-show. A research project completed a few years ago indicated that the less time between an initial phone call and a scheduled intake, the better (Stasiewicz & Stalker, 1999). According to this study, a phone call that sets up an appointment within 48 hours has the tendency to give you the best results. Under these conditions, clients will show more often than those who were scheduled longer periods of wait time, or who were given appointment cards or brochures. This study no doubt confirms many of your own experiences.

The “try it yourself” section I
This pretreatment dropout information gives you the opportunity to try out a little experiment. For example, for those of you who do not set appointment times for clients within 48 hours, tabulate the show rate for a typical month. Then phone clients and schedule appointments within 48 hours for a month. Then compare the rates of attendance for the two groups. According to the Stasiewicz and Stalker research, you should see a difference in the show rate. Of course, this experiment is not a randomized, controlled trial. So, you won’t be able to generalize far from the samples you examine. You can do one of those studies at another time. For now, all you will do is compare simple differences. This project might prompt you to conduct other basic research. And as you know, the more data you can collect on your program, the better the clinical decisions.

Program accessibility
Here are a few more researched practices that contribute to better attendance and outcome. Waltman (1995) summarized the research of the day and came up with a few key ingredients that are pre-conditions for effective care. This list is still relevant today, and we review several here.

There is no question that clients face a number of personal issues that influence treatment attendance, including motivation and possible cognitive impairments. But, they also face a number of structural obstacles placed in their way by the very programs that are supposed to serve them. For instance, the evidence indicates that if programs have long waits for admission, clients are less likely to show up for appointments (see above).

Convenience is another important factor. The evidence indicates that programs that have large distances between the facility and their clients’ homes will have an adverse effect on entering, continuing, and succeeding. To adjust for this finding, programs need to be close to public transportation and major thoroughfares. If possible, the program might offer transportation. In addition, strategically placed satellite offices are a good option to help solve the distance problem.

Another structural problem to address has to do with accommodation, or hours of operation. A good way to maintain or improve attendance and outcomes is to offer services not only during the day, but also in the evening and on weekends. The issue here is flexibility and accommodation for the client. Yes, offering such flexible services could be costly, but the attendance rates could offset the costs. To determine the importance of flexible scheduling, you might conduct an observational study, comparing flexible to non-flexible schedules to assess the impact on attendance.

Lastly, evidence is strong for better attendance and outcomes if programs offer adjunctive services such as childcare, medical services, medication, and vocational services (Institute of Medicine, 1998).

If you are pressed by an administration or board of directors that wants reasons why you structure your physical program according to some of these suggestions, you can support your claims with these data. And, for those who don’t extend your programs to include some items on list because of financial or personnel issues, the challenge would be to incorporate at least some of the suggestions listed here.

The “try it yourself” option: Follow the procedure previously outlined for the 48-hour experiment.

Stop smoking and other drugs at the same time?
Contrary to popular belief, the research indicates that quitting smoking while abstaining from other drugs does not negatively interfere with recovery (Schitz, Schneider, & Jarvik, 1997). The data indicate that smoking cessation did not contribute to relapse in abstinent smokers. For non-believers, consider that smoking is the leading cause of death in those who are treated for alcoholism. Essentially, more people with alcohol problems who smoke die from the cigarettes than the alcohol.

To get some solid guidelines on what strategies to use in smoking cessation visit, the Center for Disease Control and Prevention Web site or www.cdc.gov/tobacco/quit/canquit.htm. The information will get you started on a set of excellent smoking cessation strategies. It will link you to a host of other solid sites.

The “try it yourself” section II
Try a little experiment with this information. This is especially directed at those who still do not believe it is wise to quit all addictions at once. This experiment is designed for outpatient and partial programs, but can easily be modified for inpatient programs. First, establish a baseline of relapse with a random population of smokers who are in treatment, and continue to drink. Try to get a sample of 40 to 50 clients who smoke and have been in treatment for at least 10 sessions. Then train a portion of your program staff in the smoking cessation guidelines from the Center for Disease Control and Prevention or a local American Lung Association or Cancer Association. Have those counselors apply the smoking cessation strategies to a similar group of clients as was in the baseline group. For both groups, try to get similar demographics (gender, age, etc.), and a similar total number of clients from both groups. After about a month of smoking cessation interventions, note the relapse from this group and compare to the baseline group.

A nice addition to this quantitative approach is to take time and interview the smoking cessation group and ask them questions about how it felt to quit smoking while stopping other chemicals of choice. This is a qualitative approach and just might provide some new insights.
These suggested studies are not intended to be strict research, but are intended to get counselors comfortable with simple research procedures. I would be interested in your results.

Grouping high risk youths together
Here’s an interesting research finding that sheds some light on whether treatment programs should group high-risk youths together (Dishion, McCord, & Poulin, 1999). The results indicate you shouldn’t. In a one–year follow up study, the data indicated that high-risk youths grouped with peers actually exhibited more problem behaviors than those who were not grouped with peers. The high-risk group was defined as aggressive and antisocial adolescents. The age group of the sample was of younger adolescents, those of middle school to early high school age. So, counselors who deal with adolescents should not generalize this research finding to all adolescents in treatment. It was meant only for the described age group.

The authors hypothesized that when grouped together, youths in this age range are affected by negative peer influences. The strategy to offset this outcome is more adult involvement. Without it, these youths are vulnerable to peer influence, which could set the stage for poor outcomes.

The “try it yourself” section III
A simple experiment to test this out would be to randomly divide subjects into two groups. One group would be administered the usual treatment your program offers. The other group would get the same treatment, but would also be exposed more often to adults — say, an extra five hours per week. Then follow the two groups with a follow-up survey of 3, 6, and 12 months later to see if a difference in outcome occurred between the groups. If your program has the staff power, note the number of infractions between the groups while they are still in treatment.

As always, I would be interested in your results.

Michael J. Taleff, PhD, CSAC, MAC, is the Coordinator of the Center for Substance Abuse for the University of Hawai’i at Manoa. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
Dishion, T.J., McCord, J. & Poulin, F. (1999). When interventions harm: Peer groups and problem behavior. American Psychologist, 54(4), 755-764.
Institute of Medicine. (1998). Bridging the gap between practice and research. Washington, DC: National Academy Press.
Schitz, J.M., Schneider, N.G., & Jarvik, M.E. (1997). Nicotine. In J.H. Lowinson, P. Ruiz, R.B. Millman, & J.G. Langrod (Eds.) Substance Abuse: A comprehensive textbook (3rd ed., pp: 276-296). Baltimore: Williams & Wilkins.
Stasiewicz, P.R. & Stalker, R. (1999). A comparison of three “interventions” on pretreatment rates in an outpatient substance abuse clinic. Addictive Behaviors, 24, 579-582.
Waltman, D. (1995). Key ingredients to effective addictions treatment. Journal of Substance Abuse Treatment, 12, (6), 429-439.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2003, v.4, n.4, pp. 62-63.

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