. Natino alln st tuteo Dru gAbuse TR€ATM€NT ~ , R€S€ARCH n MONOGRAPH S€RI€S/ Treatment Process in Methadone, Residential, and Outpatient Drug Free Programs US. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration Treatment Process in ’7 Methadone, Residential, and Outpatient Drug Free Programs? Margaret Allison Robert L. Hubbard, Ph.D. J. Valley Rachal Research Triangle Institute for the National Institute on Drug Abuse U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration \ National Institute on Drug Abuse\\ i Division of Clinical Research .5600 Fishers Lane Rockville, Maryland 20857 7a :33 5/ <:> .590 ,3 z; The Treatment Research Reports, Monographs, and Manuals are published by the Treatment Research Branch (TRB), Division of Clinical Research, National Institute on Drug Abuse. TRB plans, designs, conducts, administers, and monitors research studies evaluating the effectiveness and potential impact of traditional and innovative treatment approaches, methods and techniques. One of the primary goals of the Branch is to provide information to the drug field on the findings from Branch-sponsored studies. TRB publications include state-of-the-art studies, innovative service delivery models for different client populations, innovative treat- ment management and financing techniques, and treatment outcome studies. This publication was written for the National Institute on Drug Abuse as part of the Treatment Outcome Prospective Study (TOPS), under contract number 271—79-3611 with Research Triangle Institute, Research Triangle Park, North Carolina. Harold Ginzburg, M.D. , M.P.H. , served as the NIDA Project Officer. Trade and proprietary names were used in TOPS questionnaires because it was thought the drugs were most recognizable by these names. The use of trade or proprietary names in this report does not imply that the US. Government endorses or favors any specific commercial product. All material appearing in this report is in the public domain and may be reproduced or copied without permission from the National Institute on Drug Abuse or the authors. Citation as to source is appreciated. DHHS Publication No. (ADM)85-1388 Printed 1985 H MW? 713/ / 4?? ML FOREWORD Understanding what occurs in treatment can be even more difficult than understanding whether or not the therapeutic intervention is successful. The nature of the treatment experience must be clearly understood in order to determine the contribution of that experience to changes in clients' be- havior. Distinguishing the role of treatment from that of client variables and of seemingly extraneous variables demands a knowledge of treatment components / variables . The Treatment Outcome Prospective Study (TOPS) has attempted to examine aspects of the drug abuse treatment process for each of the predominant treatment modalities/environments. This approach is particularly timely: a new treatment regimen, long-term methadone detoxification (up to 180 days), and a new chemotherapeutic adjunct, naltrexone, are about to enter the armamentarium of therapies available to clinicians dealing with substance abusers. Only by identifying treatment elements and by knowing the effec- tiveness 'of established treatments can a clinician improve the therapeutic ap- proach to substance abusers. The Treatment Outcome Prospective Study collected data at admission and in treatment on more than 11,000 clients in methadone detoxification, methadone maintenance, drug-free outpatient, and drug-free residential (therapeutic community) treatment programs. One-year and 2-year posttreatment followup interviews were collected on a stratified random sample of the 1979 cohort; 90-day and 1-year posttreatment followup interviews were collected on a stratified random sample of the 1980 cohort; and a 3- to 4-year posttreatment followup study of the 1981 cohort began in February, 1985. This report describes available treatment activities and the perception of those activities by both staff and clients. Moreover, the reader is provided an historical perspective regarding change in treatment programming where reliable data are available. Harold M. Ginzburg, M.D., M.P.H. Associate Director for Clinical Research Division of Clinical Research National Institute on Drug Abuse TABLE OF CONTENTS FOREWORD . EXECUTIVE SUMMARY . 1. 2. INTRODUCTION AND METHODOLOGY . OUTPATIENT METHADONE PROGRAMS. DRUG FREE RESIDENTIAL AND THERAPEUTIC COMMUNITIES. OUTPATIENT DRUG FREE PROGRAMS. SUMMARY AND IMPLICATIONS . REFERENCES. 31 54 71 83 EXECUTIVE SUMMARY The Treatment Outcome Prospective Study (TOPS) is a large-scale, longitudi- nal study of more than 11,000 clients who entered public outpatient detoxifi- cation, outpatient methadone maintenance and abstinence programs, drug free outpatient treatment programs, and residential therapeutic communities dur- ing calendar years 1979, 1980, and 1981. Demographic and baseline behavior- al data were collected at the initial treatment intake session. Intreatment outcome data were collected at months 1 and 3, and then quarterly for as long as the client remained in treatment. A random sample stratified by time in treatment and modality was drawn from the 1979 cohort, and these clients were interviewed approximately 1 and 2 years subsequent to treatment ter- mination. A second stratified random sample was drawn from the 1980 cohort, and these clients were interviewed approximately 3 months and 1 year after termination from treatment. A third stratified random sample has been drawn from the 1981 cohort, and these clients are being interviewed approximately 3 to 4 years after treatment termination, commencing in March, 1985. This report focuses on the goals, process and components of treat- ment in order to help better answer questions, such as: Why does treatment work, for whom does it work, and how can treatment be made to work most effectively and efficiently? Clinical/medical records were sampled in 37 of the 41 participating TOPS clinics. Intake and 3-month intreatment TOPS records, treatment plans, medication records and other relevant clinic records were reviewed. The characteristics of TOPS clinics were compared with those in the National Drug and Alcohol Treatment Utilization Survey (NDATUS). M11938 clinics WY. The methadone detox1f1cat10n» and maintenance treatment programs budgets per slot of approximately\ g2, 000. Budgets for drug free _ou_t- patient (OPDF) treatment programs were Similar. Therapeutic communities had an average expenditure of $6,135 per bed. TOPS clinics appear to reflect the continued national trend toward employing fewer ex-addicts and more counselors with advanced degrees (master's de- grees and above). The overall philosophy of the clinic directors was that abstinence was an appropriate goal. However, most of the clinic directors of OPDF treatment programs indicated that it may be an unrealistic goal. They vii based their opinions on their clients' continued use of illicit drugs while attending OPDF programs, as well as their assumptions about posttreatment levels of illicit drug use. While the demographic characteristics of the modalities vary (more males and nonwhites in the methadone modality), there appeared to be no significant changes over the 3 years of the study in client characteristics in any of the modalities. Treatment referrals from the legal system were relatively rare among methadone programs, but accounted for approximately 40 percent of referrals to both residential and OPDF treatment programs. ‘ Sixty—four 1’" percent of clients admitted to residential programs and 48 percent admitted to OPDF programs were involved with the criminal justice system in some way a--. when they entered treatment. In contrast to the patterns of 15 years ago, multiple substance abuse now appears to be the normative drug use pattern. This change suggests that a larger number of services may be necessary in treating substance abusers. Psychological problems, as well as family, social, economic, medical, and legal problems were frequently noted among clients seeking treatment. More than half the clients reported family problems and depression at treatment padmission. Forty to 45 percent of admissions to OPDF treatment programs ii reported either attempted suicide or suicidal ideation in the year before Ltreatment. Admissions to methadone maintenance treatment programs report- ed such actions or thoughts at approximately one-half the rates of drug free programs. While the overall correspondence between client reports and clinic records is high, on a number of points there appears to be a significant disparity between the two data sources. While very few clients report ever discussing their treatment plans with their counselors (or anyone else), almost all clinic charts reviewed had a treatment plan. This same dissonance also applies to receipt of specific services. In many cases, the records indicate services were administered, but the clients did not report that they had received such services. The number of services (medical, psychological, family, legal, educational, vocational, and financial) available during the years 1979—1981 varied. The trend was for fewer services to be available in the later years of study. The proportion of clients receiving family, educational, and vocational ser- vices decreased noticeably in residential treatment programs during the 3-year period. During this same period, client demand for services increased. The clients seemed to want more of everything--more counseling, more services, and generally more attention. Similar proportions of treatment clients, however, received services over the study period. Fewer received aftercare services in 1981 than in 1979. In OPDF program records, mention of aftercare ser- vices decreased from 26 percent in 1979 to 5 percent in 1981. These find- ings are antithetical to the assertions by clinic program directors about the importance of reintegration of clients into the general community and about the critical transition period from termination of formal treatment to the undertaking of productive functioning in the community. viii Low-dose methadone (69 percent of admissions were initially treated with less than 30 mg oral methadone daily) was the most common pattern of methadone treatment in the programs participating in TOPS. Forty percent of clients in methadone treatment in TOPS at least 3 months received 30 mg of methadone or less daily; 26 percent received more than 50 mg. Low-dose methadone is associated with low retention. Take-home privileges were common, but policies determining the commencement of the privilege and the number of doses varied greatly among the methadone treatment programs. Programs still appear to focus on the primary drug of abuse, rather than addressing the range of drug-related problems and social and economic functioning of the client. The large discrepancies between the TOPS clients‘ perceived needs and services received suggest that the clinic staff should question their clients more thoroughly about the existence of drug-related problems and problems related to social and employment functioning. One mechanism for increasing the availability of services to treatment clients is the establishment of better referral services through formal interagency agreements between the treatment programs and other services providers. Given the level of funding now available, duplication of services becomes a luxury. Unless cooperative ventures are developed, clients who need both substance abuse services and other community services will suffer. ix 1. INTRODUCTION AND METHODOLOGY Program administrators, researchers, and policymakers generally agree that> community-based methadone, residential, and outpatient drug free drug, abuse treatment "has been instrumental in the rehabilitation of significant< numbers of drug-dependent individuals" (National Institute on Drug Abuse \ 1981, pp. 13-14) and has been associated with favorable outcomes, especially for clients who remained in treagnentat ,1east-.3- .anth§_..(Simpson and Sells 1982). Thergismgo “question that treatment ”works- The important questions are now: Why does treatment"”‘Wo'r’k‘;""'for" whom does it work, and how can treatment be made to work most effectively and efficiently? Such questions are being asked with increasing frequency about all three major treatment modalities. Sells, in discussing results of the national evaluation of drug abuse treatment in the Drug Abuse Reporting Program (DARP), was one of the first to argue for more detailed studies of_how and why treatment works. . Although the DARP data in particular link posttreatment measures with participation in treatment, especially in the comparison of actual and expected outcomes, they do not link outcomes with treatment process. Further research should represent significant aspects of treatment process...along with measures of program capability and level of treatment "dosage.” (SellsI1979/f, p. 115) In the introduction to a comprehensive review of current knowledge about methadone treatment, Meyer stated It is clear that methadone maintenance is not a cure-all for all addicts. The failures need to be understood on the basis of the complexity of the "black box," the characteristics of the patients and of therapist/counselors, and of the mix. What are the optimal variables to examine in this pursuit as we move beyond the pre- sent state of the art? (Meyer 1983, p. 499) In their review of therapeutic communities, DeLeon and Rosenthal express the belief that ...future research must shift its focus to enhancing the quality of treatment by improving Efispt-.-manag_ement. and treatment procass-r Most evaluation efforts have asked whether TCs work, b'ut““few I 3 , have studied fly the therapeutic community works. This line of inquiry emphasizes treatment process, identifying the effective elements of a program, and the aspects of mechanisms of client change. (DeLeon and Rosenthal 1979, p. 45) Kleber and Slobetz have a similar View of outpatient drug free treatment, where little information is available on the nature of treatment. Studies which attempt to obtain followup data on sufficiently large samples to allow some generalizability of results are forced to lump together programs that may be very divergent in both philosophy and content. Even if client characteristics can be teased out of the evaluation equation, variability in programmatic approaches within the broad category of OPDF will continue to confound the results. Again, controlled studies, with carefully defined and replicable program characteristics, are the only rigorous solution to this quandary. (Kleber and Slobetz 1979, p. 37) /“ Unfortunately, to date there is little information available on treatment pro- \‘ 0655 in drug treatment programs (Allison and Hubbard, in press). Further- ‘more, much of the available data describe treatment in the early 19705. A recent survey of treatment program administrators and State agency directors (Greenberg and Brown 1984) indicated there may have been major changes in the nature of clients and treatment over the past decade, limiting the utility of much of the existing literature. More current information is clearly needed by treatment planners, program administrators, and researchers on the nature, quality, and quantity of treatment rendered in the major modal- ities. The Treatment Outcome Prospective Study (TOPS), funded by the National Institute on Drug Abuse, is a long-term, large-scale, longitudinal investiga— tion of the natural history of drug abusers who received services in publicly funded drug abuse treatment programs in 1979-1981. Although the major focus of the study is client outcomes, one of the principal goals of the TOPS «”i‘esearch is the investigation of treatment received by clients. The extensive information obtained on a variety of characteristics of treatment in outpatient , methadone, residential, and outpatient drug free programs provides the basic L data necessary to describe treatment in the modalities. The TOPS treatment process study is based on data from four sources: information from the National Drug Abuse Treatment Utilization Survey (NDATUS), the questionnaires completed by treatment directors and coun- selors in TOPS programs, the client records kept by these programs, and the TOPS interviews with the clients themselves. The following paragraphs describe the samples and instruments used for the study. SAMPLE The sample for the treatment process study included 41 clinics which partici- pated in TOPS. Within each clinic a sample of clients was selected for whom clinical/medical records were abstracted. Clinics For analyses in the treatment process study, a clinic is defined as a unit with a director or supervisor and staff providing drug treatment services at a single location. A total of 59 treatment clinics were identified in TOPS: 5 detoxification, 21 outpatient methadone, 17 residential, and 16 outpatient drug free (OPDF). Because few treatment services are provided in detoxifi- cation programs, the detoxification clinics were not included in the treatment process study. Ten of the clinics closed before the treatment process study was imple— mented. Three other clinics were very small and had fewer than five clients remaining in treatment for 3 months or more. These clinics were not consi- dered in the treatment process study. Thus, the sample includes 17 metha- done, 14 residential, and 10 OPDF clinics where samples of clinical/medical records were available. In each clinic we attempted to obtain information from the director, super- visor, or head counselor, as well as other counselors who had at least 1 year's experience in the clinic. Questionnaires were obtained from 37 of the 41 clinics. The other four clinics participated in TOPS only in 1979. Be— cause major changes had occurred in their programs and staffs, the 1981 director and counselor data were not' sought for analysis with the 1979 client data for these four clinics. Thus, data for directors and counselors in 37 clinics were used in this study, while client interviews and clinical/ medical records from 41 clinics were used. Budget and staffing data from the NDATUS for 1980 were available for 36 of the 41 clinics. Clients Samples totaling 1,351 clients retained in treatment a minimum of 3 months were drawn from the TOPS admission cohorts of 1979, 1980, and 1981 (see table 1). The overall descriptive analyses are based on this sample. TABLE 1 Treatment Process Study Sample by Modality and Admission Cohort Outpatient Outpatient Cohort Methadone Residential Drug Free 1979 202 133 119 1980 153 134 141 1981 211 155 113 533 m 373 Though basically a management information system, the Client Oriented Data Acquisition Process (CODAP) compiled some basic information on all federally funded programs and their Clients from 1974 to 1981. In a comparison of TOPS data to the CODAP reporting system, close similarities were found in client characteristics within methadone programs (Hubbard et al. 1983) as well as residential and outpatient drug free programs. Throughout the 3 years of the TOPS research, some clinics were closed and others added. In order to assess trends accurately, a group of 21 clinics that participated in TOPS all 3 years was used (13 methadone, 4 residential, and 4 outpatient drug free). The client samples from each of these clinics were given equal weighting within a modality and across each study year so that a single clinic would not affect the results disproportionately. In these Clinic analyses, clients from the smaller clinics have greater weight than clients from larger clinics. INSTRUMENTS Client data were taken from the TOPS intake and 3-month intreatment inter- views. In addition, two data collection instruments were specially designed. The Clinical/Medical Record Review Form was designed to allow data collectors to gather information from client files on a variety of topics relevant to treatment process. Sociodemographic information, as well as data on services received, treatment plans, drug use, medications prescribed, treatment history, followup services, and illegal involvement were obtained, to the extent possible, from the program records of selected clients. The Director Checklist was filled out by the treatment director at each clinic included in the TOPS treatment process study. Topics covered included program policy and philosophy, approach to treatment, emphases and goals for treatment, size of the program, caseload per counselor, services provid- ed at the program or through referral, criteria for completion of the program or for discharge from the program, and many other variables relevant to the study of treatment process. Counselors completed a similar Counselor Check- list asking about their perceptions on these topics. Both the Record Review Form and the Checklists were pretested in one out- patient methadone, one outpatient drug free, and two residential TOPS programs. Based on the findings of the pretest, some revisions to the instruments were made and a comprehensive instruction manual was prepared to guide data collection. Supervisors randomly reabstracted 10 percent of, the records for each data collector to check the quality of the data. APPROACH This report uses the available information about drug abuse treatment in the TOPS programs to answer five major questions: 0 What is the nature of treatment available and rendered in a large national set of selected methadone, residential, and outpatient drug free programs? In this report, we first describe the characteristics of treatment process in clinics within each of the three major modalities. Due to the lack of a clear and comprehensive definition of drug abuse treatment process, we studie the major stru nts: program and staff, goals and philosophy of treatment, approaches to counseling, treatment plans and process, services ailable to and received by clients and, finally, evidence of clients' satis- faction with treatment. 0 How useful is this information to treatment programs? TOPS is based on a purposive sample of large, urban, stable, well-establish- ed programs. Thus, these data do not represent all treatment programs, but the study results can be used to address many of the key issues facing all programs and should be very useful fo la ners adminis- __t_rators, and, researchers. The National Drug and Alcoholism Treatment Utilization Survey (NDATUS) is a management information system that com-]% piles information WWQmQW, staffin , and treatment capacity and utilization for all private and public alco o and drug treatment programs in the United States as well as information from other sources such sgovemment agencies. TOPS programs are compared with NDATUS pro- grams ?0 identify major similarities and differences between them. 0 How has drug treatment changed over the past decade? To provide some historical perspective, the major studies in the area and major review articles are cited. However, most studies are based on informa- tion from a single program or small group of programs, and detailed client characteristics and treatment process are seldom reported. These studies are most useful in identifying the major variables that have been studied over time. Because most studies were conducted in a single time period, they have limited value in determining how particular characteristics or treatment elements have changed over time. In general, change must be inferred from general impressions about programs rather than from statis- tically reliable data collected over 2 or more years. 0 What changes might occur in the future? Trends over the 3 years of TOPS, based on client self-reports and clinical/ medical record checks, are discussed. Should these trends continue, treat- ment should be adapted to these trends. The statistical significance of differences among the distributions for the three cohorts was determined by a chi-square test. Results that are discussed have clinical as well as statis- tical significance (see Feinstein 1977, pp. 320-334). 0 What are the implications of the findings? A final chapter summarizes the results, compares the modalities, and dis- cusses current and future implications for treatment programs, policymakers, and researchers. 2. OUTPATIENT METHADONE PROGRAMS In the 19605 the success of a methadone maintenance program at Beth Israel Hospital in New York (Dole and Nyswander 1965; Dole et al. 1968) demon- strated that long-term opiate addicts could be treated successfully with a daily oral dose of methadone. _By the early 19705, it was an accepted mode of treatment for opiate abuse. Regulations were established jointly by the Food and Drug Administration and the National Institute on Drug Abuse (U.S. Department of Health, Education, and Welfare 1972). The number of methadone maintenance clinics increased rapidly between 1970 and 1973, and by the late 19705 over 75,000 heroin addicts were being treated in methadone maintenance treatment programs across the United States (Lowinson and Millman 1979). In 1982, the 71,000 clients in outpatient methadone programs represented 41 percent of all clients in drug treatment units (National Insti- tute on Drug Abuse 1983). Important advances have been made in understanding the nature of metha- done treatment and its impacts on outcomes (Cooper et al. 1983). Despite continuing controversy about philosophy, duration, dosage, and approaches, the general approach to treatment has not changed markedly. The last Federal regulations governing methadone maintenance treatment programs specified certain admission, service, and documentation requirements. The regulations defined maintenance treatment using methadone as "the continued administering or dispensing of methadone, in conjunction with provision of appropriate social and medical services, at relatively stable dosage levels for a period in excess of 21 days as an oral substitute for heroin or other morphinelike drugs, for an individual dependent on heroin" (U.S. Depart- ment of Health and Human Services 1980). Programs were required to obtain a personal and medical history for each client. The programs were also to provide a comprehensive examination including any lab or special exams indicated in the judgment of the attending physician. Although social rehabilitation is clearly one of the goals of methadone treat- ment, the regulations only suggested that programs make available various services such as' vocational rehabilitation. How methadone programs ap- proach rehabilitation and the methods they use to accomplish this goal are the principal focus of this chapter. SIZE AND STRUCTURE Methadone clinics vary in size and structure. They also differ in how they are organized within the health care delivery system and the community. In 1982 about half of all 516 maintenance treatment units reporting to NDATUS were free-standing facilities, 15 percent were in community mental health centers, 15 percent were in general hospitals, and the remaining 20 percent were in a variety of other settings (National Institute on Drug Abuse 1983). NDATUS clinics had an average enrollment of about 200 clients. TOPS methadone clinics tended to be larger than the typical clinic and to be organized differently. The 17 clinics participating in TOPS had, on aver- age, just over 260 clients. Fourteen of these clinics had between 200 and 400 clients. In terms of organization, 10 of the TOPS clinics were affiliated with large hospitals. These clinics, however, were generally located in the community; only two were on hospital grounds. Six of the remaining clinics were operated by independent community organizations. The other was part of a multimodality drug abuse treatment agency administered by the county government. Over two-thirds of clients in all clinics said the program was easy to get to. Most clinics had been in the same location for a number of years, indicating community acceptance. Only three of the 17 clinics changed location during the course of the study. The 17 TOPS methadone clinics had an average annual budget of $1,945 per client, somewhat less than the $2,174 for the typical clinic reporting to NDATUS. Only three TOPS clinics had per-client budgets higher than the NDATUS average. All clinics received funding from State governments, and nine had NIDA statewide services grants or other 410 grants/contracts. Client fees made up more than 10 percent of the five clinics' budgets. Public health insurance provided almost half of the funding for the seven clinics of one large program. Clinics also obtained funding from the Bureau of Prisons (3), Comprehensive Employment Training Act (CETA) programs, (3), local government (1), and private donations (1). It appears that all the TOPS clinics were based largely on public funding; however, most re- ceived funding from a variety of agencies. STAFF 4a Clinic staff may well be one of the most important determinants of the sue-“fl cess of a program Lowinson and Millman (1979) recommended that staffing ) ' patterns be developed to meet the psychosocial needs of the patient. In j addition to the obvious need for physicians and nurses in methadone pro-/ grams, they recommend employing a psychiatric social worker and counselors“ with specialized areas of expertise. Staff Composition NDATUS data show that methadone programs do indeed have a high level of medical care. About 6 percent of full-time paid staff hours are provided by physicians and 25 percent by nurses and other medical staff Counselors, social workers, and psychologists account for about 40 percent of the staff hours. These patterns (see table 2) did not appear to change over the/ period 1979 to 1982 (National Institute on Drug Abuse 1980,1983) \ ’v/WMW" “"" "" x J 7 TABLE 2 Percentage of Hours Worked by Different Types of Staff in NDATUS Outpatient Methadone Programs in 1979 and 1982 Type of Staff 1979 1982 Physicians 5.7 5.0 Psychologists 1.0 2 . 8 Nurses/Medical 25.0 25.2 Social Workers 7.2 5.5 Counselors 30. 7 31 .7 Bachelor's Degree 14.8 N/A Associate Degree 2.8 N/A Nondegreed 13.0 N/A Other Direct Services 2.6 4.6 Administrative/Support 27.8 25. 1 All Staff 100.0 100.0 n=2501 n=4633 In the TOPS programs, Q1e ratios ion physicians were generally the same. However, in other areas ere were very erent staff mixes. In four‘ clinics, medical personnel worked less than 20 percent of the hours. Medical staff worked more than 30 percent of the hours in nine clinics and between 20 and 30 percent in the other four. The hours worked by direct service staff (psychologists, social workers and counselors) varied greatly among the clinics. In six clinics more than half the full-time hours were worked by counseling staff. In another eight clinics, all affiliated with hospitals, counselors worked less than one-third of the full-time hours. The staffing pattern differences suggest service orientations that emphasize medical or social rehabilitation. There is, however, no clear correlation of these findings with the clinic directors' or counselors’ perceptions of treat- ment philosophy or orientation. Clearly, these staffing patterns could direct- ly- and indirectly influence the nature of services and outcomes. How and to what extent is an open question. Staff Experience The contribution of staff characteristics and functioning to outcomes may be one of the most difficult and controversial processes to quantify. At best, we may only be able to describe general measures of staff qualifications such as education or whether or not they are former addicts. In TOPS we looked at the level of education and experience of program directors and counselors. The clinic directors averaged 34 years of age; about half were women and about half were minority group members. All but 4 of the 17 directors who responded had at least a bachelor's degree and 7 had master's degrees. They had an average of nearly 7 years' experience in drug abuse treatment. Ten had been at the same program for at least 2 years, five of these for more than 5 years. TOPS programs, then, had retained clinic directors with a high level of formal education as well as extensive experience in drug treatment. Counselor characteristics, education, and training could be important factors ' ' ' ' why-.clients, Reviews (Allison and Hubbard in press; Hall 1983; Woody 1983) and numerous empirical studies (Brown and Thompson 1973; Longwell et al. 1978; LoSciuto et a1. 1979) have provided no definitive evidence of the superiority of counselors with a particular educa- tional or experiential background. Still, as Greenberg and Brown (1984) reported, there is a trend toward improving the formal education and creden- tials of counselors. In the 1979 NDATUS, about half of the paid _C()1.11'1§S3,19.r S inwmethadone” programs had at least abachelor's ' degree. Seven percent of the full-time staff hours were provided by professionally trained/ degreed social workers. ' In the TOPS outpatient methadone programs, questionnaires were obtained from 38 counselors with at least a year of experience in the program. Of these, 23 had bachelor's degrees and 14 had master's degrees. Only two counselors did not report having some college courses. Counselors also tended to be mature and to have considerable experience in drug treatment in general as well as in their current programs. Their ages ranged from 27 to 56, with a median age of 37. Experience in drug treatment programs averaged 7 years. Twenty-six of the counselors (68 percent) had spent almost all of their drug treatment careers in their current programs. Ex- addicts participated in counseling to some extent in most programs. They were very active in four clinics but did no counseling in three. In general, the results from the TOPS methadone clinics suggest a relatively high level of formal education for counseling staff. Professionally trained counselors are replacing ex—addicts in the primary counseling of clients. Experience with drug treatment and long tenure in their current programs are also signs of staff stability. APPROACHES AND GOALS fl 6Q D'Amanda (1983) reviewed a number of issues related to the effects of policy on outcomes of methadone programs, W$W~We§-«mfi&' tena ce ve sus abstinence. Although the da a are limited, he concluded that policies regarding me adone administration affect the quality and effective- 29/ :6 ness of treatment. \/ Dole and Nyswander (1965) have held that supportive social services such as psychotherapy, vocational training and educational programs are essential parts of treatment. Newman (1977) agreed that methadone by itself cannot be a complete treatment for heroin addiction but also pointed out that the kinds of services needed and the special role of psychological counseling are still subjects of considerable debate. Lowinson and Millman (1979) asserted that "severe social and psychological disability is frequently a product of the drug-dependent life" and appropriate services are necessary to overcome these disabilities. Thus, the basic approaches or policies of most methadone programs empha- ii£§wphysiolggical stabilization and thetprovision ”qurheAsg-ujwrcgswmjt W229. , ~t—~\ Types of Approaches Graff and Ball (1976) discuss two models of methadone treatment: the "meta- bolic" and the "psychotherapeutic." According to the metabolic model, drug abuse is primarily a "metabolic disease, reflecting a specific physical or biochemical deficit. This deficiency is expressed symptomatically as a crav- ing for an opiate drug and is corrected by the administration of a corrective substance" (p. 141). The corrective substance is a daily dose of methadone. Services and therapy are viewed as adjuncts, and abstinence is not a major goal of treatment. In the psychotherapeutic model, drug abuse is seen as a symptom of a primary emotional disorder. In this model, methadone is ad- junctive to the principal (psycho)therapy. Eventual abstinence from metha- done is an important goal of treatment. These models are similar to the two types of programs that were identified in the DARP research (Cole and James 1975). Change—oriented programs are designed to assist the patient to achieve eventual drug-free living as a result of treatment, to totally resocialize the addict so that he can return to unsupervised community living, and the development of instru- mental social skills (p.40). They go on to describe treatment as having restrictive admission criteria, typically prescribe methadone at as low a level as the patient can tolerate, emphasize scheduled thera- peutic counseling, are typically located in large institutions, have rigid dispensary hours within a structured framework of thera- peutic activities, and provide special services for patients in withdrawal or aftercare phases of the treatment program (p.40). Adaptive programs attempt to provide continued counseling and support to patients, all of whom are expected to continue indefinitely on methadone, to develop a sense of trust in the program staff and people in general, and to develop vocational skills that will allow the addict to hold a job (p. 40). The characteristics of these programs include a fairly open admission policy, methadone doses that are consi- dered blocking doses, counseling provided as dictated by the patients' needs, a treatment facility located near the addict's neighborhood, a minimum of structured therapeutic activities, and no provisions for withdrawal and aftercare (p. 40). In the DARP, two-thirds of the 26 programs were described as adaptive. In TOPS only one-fourth of the clinic directors identified their programs as 10 A, adaptive. Although neither TOPS nor DARP is a statistically representative sample of all methadone treatment programs, these results suggest a shift in the overall philosophy of methadone treatment. Maintenance Versus Abstinence Clearly, the controversy over long—term methadone maintenance versus methadone-to-abstinence programs has implications. for program planning, policy, services offered, definitions of success, funding, staffing and a myriad of other issues. The Federal regulations governing methadone main- tenance treatment accommodated both positions. They stated that "an even- tual drug-free state is the treatment goal for many patients; it is recog- nized, however, that for some patients the drug may be needed for a long period of time" (U.S. Department of Health and Human Services 1980). Woody (1983) cited studies of successful detoxification by clients with good records in treatment (Stimmel et al. 1977) and under gradual dose reductions (Senay et a1. 1977). Given that some proportion of maintenance clients may achieve abstinence, key questions are how many, how can they be identified, and what is the risk of misidentification? Cushman (1977) and Newman (\977) both question the wisdom of a government policy that encourages detoxification of clients maintained successfully on methadone. Dole and Nyswander (1976) point out that many clients are refused supportive ser- vices once they have achieved abstinence--the period when they are most likely to need these services. Newman (1983) advocates more attention to client goals, needs, and response to treatment in order to assess the risk of relapse and the necessity for continued maintenance. He also cites regula- tory, social, and medical pressures on programs to encourage their clients to attempt detoxification. Among TOPS programs, three of 17 clinic directors described their programs as methadone—to-abstinence programs. Twelve of the directors (71 percent) said they encouraged abstinence to a great extent. Ten of the directors (59 percent) said detoxification was generally initiated on client request. These results indicate a move toward abstinence not apparent a decade ago when maintenance programs appeared to discourage their patients from at- tempting to detoxify from methadone (Glasscote et a1. 1972, p. 34). Despite the apparent support of abstinence in some cases, all but one of the directors said they also supported long—term maintenance to some extent; five (29 percent) encouraged maintenance to a great extent. Nine of the clinics (53 percent) had at least 75 percent of their clients on long-term (over 1 year) methadone maintenance. In all but one clinic, over half of the clients were in long-term (over 1 year) maintenance. Attitudes Toward Methadone The agbivalegce, especially regarding maintenance and abstinence, expressed in the Federal regulations and by treatment directors may be reflected in staff and client attitudes. Levine and Kabat (1975) interviewed clients in a methadone treatment program and found that, while clients were quite aware of all the rules regarding the use of methadone, they did not understand the overall treatment plan or program goals. Brown et al. (1975) found consi- derable ambivalence toward methadone, including concerns about dependence ll /._ and side effects. Hall (1983) reviewed these and other studies on client and staff attitudes. She concluded that, although clear empirical data were not available, attitudes might greatly influence treatment outcomes. Ambivalence was reflected in the responses of the 38 TOPS methadone coun- selors to questions about maintenance and abstinence. Of the 37 counselors answering the question on whether or not they encouraged abstinence, 14 (38 percent) reported encouraging it to some extent, 16 (43 percent) to a great extent, and 7 (19 percent) to a very great extent. In terms of en: couraging maintenance, 6 reported encouraging maintenance to a great extent, 24 to some extent and 7 did not encourage maintenance at all. Despite the variety of responses, most of the counselors (84 percent) indicated that over half of their clients were in long-term maintenance. Attitudes did not appear to affect dosage levels or the proportion of a counselor's caseload on long- term maintenance. Clients may be ambivalent about their own methadone treatment if there is no clear program philosophy. Programs should, therefore, develop a coherent and unified policy, especially toward criteria and alternatives for abstinence and maintenance. A clear position and policy on this critical issue could improve staff functioning and help clarify the issues for clients in their decisions about their course of treatment. CLIENT CHARACTERISTICS p. The nature of the client population can, in large part, determine the orienta- \tion, staff, services, and outcomes for a program. Lowinson and Millman (1979) cited the variability in individual, social, ethnic, and geographic characteristics among narcotic users. McLellan (1983) argued that although "overall effectiveness" of methadone treatment has been demonstrated, more information is needed on how particular types of clients respond to treat- ment. Factors contributing to better adjustment during methadone main- tenance, according to McLellan, included greater maturity, less criminality, and better social and psychological supports. In TOPS programs a number of these client characteristics were examined. Nearly two out of three TOPS methadone clients were men and about 40 per- cent were over 30 years old. Less than half the clients were white, and less than half had finished high school. About half had no full-time, legiti- mate employment during the year before they entered treatment. TOPS methadone clients were less likely to be involved in crime than clients in previous studies. Only about a third of the clients were involved in violent or predatory income-generating criminal behavior other than drug sales in the year prior to treatment in the TOPS clinic. About 70 percent of the TOPS methadone treatment clients were using heroin weekly or more often during the year before admission. Ten percent had not used heroin but used other opiates. The rest of the clients were former heavy users who transferred in from other programs or agencies, or were readmissions. About a fourth of current "other opiate" users used a variety of drugs. Almost all clients reported weekly alcohol and/or marijuana use. Most of the TOPS methadone clients were referred to treatment by them- selves, their families, or their friends; almost none was referred by the 12 legal system. Nearly three out of four clients had been in treatment before, and over one-third had previously been in treatment three or more times. Roughly half had some kind of health insurance coverage, usually Medicaid, according to the clinic records. Data from the six methadone programs that participated in all 3 years of the study were analyzed for trends over the 3 years. The results of these analyses indicate that the clientele changed very little in most respects. There was a trend toward more self-referrals to treatment (x2 = 12.7, p <.05), according to the clinic records, and the clients’ average age seems to have increased (x2 = 19.8, p (.05). In general, however, the clients' characteristics, as discussed above, remained fairly stable over the 3-year period. Even the trends noted for age and referral source were moderate (table 3). TABLE 3 Trends in Age and Referral Source Among Clients in Outpatient Methadone Programs Cohort 1979 1980 ‘ 1981 Variable n=186 n=106 n=139 9 9 9 0 0 0 Age <26 25.6 20.8 15.7 26-30 39.9 37.8 35.7 >30 34.5 41.5 48.6 Referral Source Self 58.6 69.0 71.9 Family or Friends 13.6 14.9 15.5 Legal System , 6.4 2.0 4.1 Other 21.5 14.1 8.6 aOnly the six methadone programs that participated in all 3 years of the TOPS were included in this analysis. , Despite the fact that there were great similarities among most of the TOPS methadone clinics, there were important variations. Although no TOPS pro- grams were specifically designed for women, in two clinics over half the clients were female. In another, over half the clients were 25 years old or under. The proportions of black and Hispanic clients appeared to vary with clinic size. In all TOPS clinics with under 300 clients, the majority of clients were white. In clinics with more than 300 clients, a majority of the clients were black and/or Hispanic. This would suggest that larger clinics are more likely to be found in inner city areas and to serve an inner city population with significantly less education and work experience, and other characteristics that lower the probability of rehabilitation. For example, in these larger clinics, less than one-quarter of the clients had high school diplomas compared to over half the clients in smaller clinics. 13 Two other variations are worthy of note. In seven clinics, more than 20 percent of the clients reported that this was their first treatment episode. In the other clinics about 9 of 10 clients had a previous treatment experi- ence. Drug use patterns also differed. In clinics in two cities, most of the clients were principally current heroin users (75 percent) or former daily users who most likely transferred from other programs. For clients entering treatment in the other six TOPS cities, substantially more used both heroin and other opiates (40 percent) as well as opiates other than heroin (15 per- cent). The assessment of how these client characteristics and behaviors interact with treatment services and affect outcomes is very complex and beyond the scope of this report. The sobering fact is that it may be more difficult than most researchers and treatment administrators had expected to determine what kinds of treatment work best for which types of clients. It appears that clients with particular characteristics and behaviors prefer different types of clinics. These combinations of client and clinic characteristics must be carefully considered in evaluating treatment outcomes. Is it the charac- teristic of the client, the nature of treatment, or their interaction that leads to effective treatment? PROBLEMS PRESENTED AND ASSESSED Lowinson and Millman (1979) called for staffing patterns that meet the psy- chosocial needs of clients. They cited the severe social and psychosocial "byproducts" of addictions. Woody (1983) and McLellan (1983) reviewed studies that confirm that many clients entering methadone clinics have a variety of psychological problems severe enough to warrant extensive therapy. In the TOPS clinics, the clients‘ drug, drug-related, and nondrug-related problems were studied in several ways. The clients were asked about such problems at intake and during treatment, and their clinic records were examined. In addition to drug and alcohol behaviors, the TOPS also studied clients' problems in seven other areas including medical, psychological (mean- ing mental, emotional, or behavioral problems), family, legal, educational, employment, or financial. These problems are described as the clients reported them and as the treatment programs' intake workers, counselors, and other staff members viewed them. Nature of Problems At intake, the TOPS methadone clients said their drug abuse had caused them problems of several different kinds: medical (34 percent), psycholog- ical (38 percent), family (51 percent), job (27 percent), legal and/or finan- cial (61 percent). The TOPS interviews also asked whether the clients had felt so depressed they could not get out of bed, had thought of suicide, or had attempted suicide during the year before entering treatment--three rather serious indicators of depression. Over half the clients said "yes" to one or more of these questions; about 5 percent said they had attempted suicide during the year prior to treatment. The primary problem identified by the clinic staff was drug abuse in nine out of ten cases. About one-third of the files contained a notation of a 14 secondary problem. These were about evenly scattered among psychological, employment, financial, and medical problems. The clients' presenting com- plaints were also drawn from the files. In 90 percent of the cases, drugs were one of the presenting complaints, but a few records also noted employ- ment, financial, psychological, or other problems. The clinic records also yielded information, mainly from the counselors' case notes, about any problems the clients had during treatment. About 20 per- cent of the files noted medical, employment, and psychological problems, and nearly that many had notations of family and legal problems. Service Needs The clients were interviewed again after they had been in treatment for 3 months. At that time they were asked if they thought they needed services for problems in any of the seven areas. Forty percent or more said they needed medical, employment, and/or financial services; 25 to 30 percent said they needed services for educational, psychological, and/or family problems. Table 4 shows the percentages of clients who reported each problem at intake, who were noted by clinic staff as having problems, or who felt they needed services for various problems. TABLE 4 Problems Presented at Admission and During Treatment in Outpatient Methadone Programs (n=566) Type of Problem Psycho- Educa- Finan- Medical logical Family Legal tion Job cial 9 9 9 9 9 9 9 Client Self-Reports ° ° ° ° ° ° ° of Drug—Related 34.2 38.1 50.9 18.2 26.6 60.9 Problems at Admission Presenting Complaint (other than drug 3.6 5.8 4.3 4.6 0.0 9.0 6.6 abuse) as Noted in Clinic Records Problems During Treat— ment (other than drug 23.6 18.8 16.7 14.2 3.4 21.3 10.8 abuse) as Noted in Clinic Records Clients' Perceived Need for Services 46.8 29.8 26.1 16.4 31.2 38.9 36.9 After 3 Months in Treatment In all seven areas, the percentages of clients who said they had problems or needed services were larger than the percentages indicated by the clinic records. Whether this means that some clients think it is inappropriate to 15 mention these other drug-related or nondrug-related problems or that the clinic staff did not probe and/or not note these areas is unknown. Many clients felt they needed services for a variety of problems. While such expressions are not, by themselves, unequivocal indicators of need, it may be that further assessment, provision of services, and/or referral to other, more appropriate service agencies would be useful additions to methadone treatment programs. Staff in methadone clinics should probe these areas and note both the objective and subjective evidence of problems in each area, their severity, and their relationship to drug use. Trends The data on client problems were analyzed for differences across cohorts which might suggest trends in service needs. The chi-square test was used to determine the significance of the differences. Again, only the 13 continu- ing methadone clinics were included in this trend analysis. The analysis revealed virtually no differences that suggested trends. Most of the statis- tically significant differences found were slight and sporadic. There are four exceptions to this general finding. First, there were slight trends toward reports of fewer drug-related problems both at admission (x2 = 12.7, p <.05) and after 3 months in treatment (x2 = 13.7, p <.05) and fewer reports of depressive symptoms at admission to treatment. Trends toward more reports of drug-related medical problems and of perceived needs for medical services were found. Fewer drug-related family problems and fewer perceived needs for family or psychological services were reported in 1981 compared to 1979. In all other problem areas, there were no significant differences. Table 5 shows the differences among the three cohorts in the number of different types of drug-related problems they reported at admis- sion and after 3 months in treatment. The differences in reports of only medical, psychological, and family problems are presented because no trends were found in other areas. In general, it would appear that client problems did not increase in methadone clinics. If current services are meeting the needs of clients, no drastic revision in services is necessary. 16 TABLE 5 Trends in the Number and Types of Drug-Related Problems Reported by Clients in Outpatient Methadone Programs Cohort 1979 1980 1981 Variable n=186 n=106 n=139 O O 0 Number of Problems /" 7’ 7’ Reported at Admission None 22.0 18.8 18.5 1-2 35.4 41.6 44.5 3-6 42.6 39.6 37.0 Types of Problems Reported at Admission Medical 28.5 38.8 40.6 Psychological 43.0 26. 5 38. 2 Family 57.0 46.2 43.7 Perceived Need for Services Reported After 3 Months in Treatment None 77.4 82.7 90.2 1-2 14.8 9.1 7.5 3—6 ' 7.8 8.2 2.3 Types of Problems Reported After 3 Months in Treatment Medical 41.6 33 .4 59.1 Psychological 38.3 17.0 20.4 Family 38.4 14.1 14.2 Variation in Need by Clinic The individual methadone clinics deal with client populations that differ greatly in the number and types of drug-related problems. For example, in three clinics, half the clients reported having drug-related problems, com- pared to 75 percent in the other clinics. In four clinics over half the cli- ents reported drug-related medical problems, compared to less than a fourth in eight other clinics. In nine clinics over a third of the clients had suicid- al thoughts or had attempted suicide in the year prior to treatment. In five other clinics less than 20 percent of the clients reported this level of distur- bance. Again, the client subpopulations serviced by particular clinics may need very different levels and mixes of services. For example, high proportions of clients with depressive symptoms and high proportions of clients with drug- related medical problems might require different staffing than a program with low proportions of clients with one or both of these problems. Again, we cannot at this time determine why clinics have different problem mixes or how these mixes are related to treatment rendered and outcomes. These issues will be a focus of subsequent analyses of the TOPS intreatment and followup data. 17 TREATMENT PLAN AND PROCESS ‘ The treatment plan has been considered an essential part of treatment. Federal Funding Criteria required that plans be developed with the knowl- edge of the individual client and be updated periodically. Lowinson and Millman (1979) suggested that plans for methadone clients be developed by a social worker and reviewed and modified as necessary every 3 months. A GAO report on all treatment modalities concluded that treatment plans are "often incomplete, vague, or missing... and that even when present they are not periodically reassessed" (U.S. General Accounting Office 1980, pp. 31-32). . During the TOPS interview, three-fourths of the clients said they had not received a formal, written treatment plan. This was surprising in view of the fact that over 90 percent of their files contained treatment plans which they had signed: in 14 of the 17 clinics, treatment plans were found for over 98 percent of clients. Evidently, the clients did not understand what the treatment plan was. Perhaps the TOPS interviewer and the program staff referred to the plan in different terms or perhaps the plan was signed along with several other papers and the client simply did not recall it. One reason may be the clients' limited involvement in the development of plans. In seven TOPS clinics, staff members said clients were involved only to a limited extent in the development of their plans. Most of the recorded treatment plans had been developed by an MSW or other member of the counseling staff. Six program directors reported that the social worker usually developed the plans. The other clinics used coun- selors and other staff. Eleven of the TOPS clinic directors (65 percent) said treatment plans were developed within a week after admission. Most said their treatment plans were updated at least every 3 months. The majority of the plans found in the records had been updated at least once, and about one-fourth had been revised four or more times. More generally, directors also commented on their treatment process. Most clinics admitted clients into the program within 1 or 2 days of initial contact. However, six clinics (35 percent) had an initial trial or review period of from 3 days to 2 weeks before the client was officially admitted to the pro- gram. Eleven (65 percent) also said the usual planned duration of treatment in their programs was 18 months or more. Only four (24 percent) of the clinic directors indicated they emphasized formal designation of phases or stages of treatment for clients. The treatment process in TOPS methadone clinics follows what has traditional- ly occurred in methadone clinics. Records of treatment plans do appear to be much better in the TOPS programs than was found in the GAO study. Still, the finding that clients have minimal knowledge of and involvement in the preparation and review of their treatment plans is troubling. Treatment plans are advocated as an important, if not the most important, element in successful treatment. Yet most clinics do not appear to be using treatment plans appropriately. Clearly, more client involvement is necessary. Much of the ambivalence about treatment goals (Brown and Thompson 1975), especi- ally in methadone programs, might be reduced if a plan was clearly written and discussed in detail with a client. 18 POLICIES AND PRACTICES FOR THE USE OF METHADONE The subjects of methadone dosage, urine testing, take-home policies, and the use of psychotherapeutic medication are controversial. The resolution of these issues is beyond the scope of this report. We do think it is informa- tive to describe practices in the sample of community clinics in TOPS. Dosage Level Hargreaves (1983) carefully reviewed the many studies of methadone dosage. He concludes that dosage levels do have an effect early in treatment. Be- cause dosage levels of 100 mg have proven to be therapeutically effective with 10-30 percent of clients, he advocates freer use of high dosage levels. Despite the evidence cited by Hargreaves, there has been a trend toward lower dose levels over the past decade (D'Amanda 1983). NIDA reported that current typical dose levels are 20-39 mg (Brown et al. 1982-1983). In a critique of the Hargreaves review, Goldstein and Judson (1983) stated that dosage may be relatively unimportant above a given "effective dose." Other factors in treatment are viewed as more critical to outcomes. The current tenor of the research literature (Goldstein and Judson 1983; HargreaVes 1983; Woody 1983) indicates that dosages around 80 mg are effective for a large proportion of clients. Lowinson and Millman (1979) advocated between 20 and 40 mg at the beginning of the induction phase. They also reported that higher maintenance doses, 70-100 mg, contributed to "a wider margin of safety." Table 6 shows the methadone dosage levels for TOPS clients and the per- centages of clients receiving those levels at admission and at 3 months in treatment. At admission, the vast majority of clients received 10 to 40 mg/day. This is generally consistent with the recommendation of Lowinson and Millman. At 3 months in treatment 40 percent of clients were receiving methadone doses below 30 mg/day though virtually all researchers advocate maintenance dosages of 40 mg or more. The TOPS clinic records showed clear trends over time toward smaller doses of methadone being prescribed both at admission (x2 = 26.6, p <.01) and at 3 months in treatment (x2 = 38.6, p <.01). TABLE 6 Methadone Dosage Levels Prescribed at Admission and at 3 Months in Outpatient Methadone, Based on Clinic Records (n=566) Dosage Level in mg/Day 0 1-10 11-20 21-30 31-50 51-70 71+ 9 9 9 9 9 9 I; 0 O O 0 0 0 0 At Admission 3.1 6.4 31.8 27.9 22.3 5.6 2.9 At 3 Months 5.5 4.5 10.1 20.0 33.7 16.5 9.7 l9 The clinic directors were asked to provide information on the usual long-term maintenance dosage. Two clinics prescribed daily maintenance doses of 10-24 mg, seven prescribed 25-49 mg and six prescribed 50-74 mg. One clinic director said the usual maintenance dose was in the 75-99 mg/day range, and one director failed to respond to this item. Clinic records were consistent with the directors' answers. We found only three clinics (two were part of the same program) in which more than half the clients were receiving dosages in excess of 50 mg after the first 3 months in treatment. Urine Testing Federal regulations required weekly urinalyses for the first 3 months in a program, and then monthly random urinalyses (Lowinson and Millman 1979). D'Amanda (1983) and Lowinson and Millman questioned the benefits of urin- alysis given the costs in staff time, expense of the analysis, and possible negative reaction of clients. Havassy and Hall (1981) could find no signifi- cant differences between monitored clients and a group that was not required to provide urines. Despite the controversy and lack of evidence of its efficacy, all clinic direc- tors reported urine samples were collected weekly during the first month in treatment. Urinalysis results were included in the clinical/medical records for 84 percent of TOPS methadone clients. Take-Home Policy A third element of controversy in methadone treament involves take-home policy. After demonstrating a commitment to, rehabilitation for 3-12 months, clients can be granted take-home privileges (D'Amanda 1983; Lowinson and Millman 1979). Some studies (Dole et al. 1971; Patch et al. 1973) indicate denial of take-home medication has negative effects. However, D'Amanda concluded that, after other factors are taken into consideration, take-home medication does not affect retention. He cites the study by Havassy and Hargreaves (1979) as evidence that take-home privileges have minimal effect on behavior. Potential diversion (Inciardi 1977) is clearly one of the major concerns about take—home privileges. According to the directors of eight TOPS clinics, after 3 months 75 to 100 percent of their clients have some take-home privileges. In three other clinics, 50 to 75 percent have take-home privileges, and in the remaining five clinics, less than 50 percent have such privileges. One director did not respond to this item. In general, checks of the clinic records confirmed the responses of the directors. Despite the controversy surrounding take-home policies, in the TOPS clinics, the practice is common. Psychotherapeutic Medication Kleber (1983) reviewed the use of other psychoactive drugs in methadone programs. Because a number of clients have severe psychopathology that may affect treatment outcome, Kleber, Woody (1983), and Lowinson and Millman (1979) have advocated careful use of psychotropic medication. Klein (1983), however, points out that some treatment staff will not support the use of medication that has a potential for abuse. 20 Only five of the 17 clinic directors said that psychoactive drugs other than methadone were prescribed. Four reported the use of minor tranquilizers; three reported use of major tranquilizers. Checks of clinical medical records indicated the number of clients prescribed these drugs was very low. Still, the small number of clients with psychiatric problems who enter methadone programs should have access to appropriate psychiatric care, including psychoactive medication where indicated (Lowinson and Millman 1979). The low level of psychoactive drugs prescribed may be an indicator that the clients are not receiving appropriate diagnosis and referral. WOUNSELING Counseling is one of the key elements of methadone treatment. Federal regulations required a minimum of one counseling sessmn per month. What should be included in these sessions was not specified. Researchers have reported on a variety of counseling approaches that are used in individual programs. Woody reported positive effects with a variety of psychothera- peutic approaches combined with drug counseling. Hall (1983) reviewed studies of the effects of contingency management. Hall is properly concern- ed "whether such orderly models will be effective in the lively atmosphere of the typical methadone clinic. " Despite these more elaborate models'of extended counseling, there is little description and definition of what constitutes basic "drug counseling." Lowinson and Millman tried to delineate some of the major aspects of counsel- ing, such as developing an identification with the program, communicating rules and regulations, identifying rewarding alternatives to drug use, and discussing practical, everyday problems. It becomes obvious that many components of drug counseling are difficult to describe, document, or quan- tify. In the absence of clear clinic records on counseling sessions, it was difficult to determine the nature, quantity, and quality of counseling. It was also difficult for clients in some clinics to distinguish clearly a full counseling session from more informal, ad hoc contacts with counselors. The latter type of contact, which frequently occurs for specific small crises, may be a major factor in outcomes that cannot be adequately documented. Caseload Time is an important element in counseling. The time available for counsel- ing is, in part, reflected in the counselor caseload. Lowinson and Millman (1979) recommended a caseload of 50 clients. Woody (1983) suggested that a caseload of 35 is a more "workable" number. He also noted that only about 60 percent of a counselor's time, or 24 hours per week, is available for direct patient contact. With a caseload of 50 clients, only about one-half hour a week is available for individual sessions with each client. Of the 17 TOPS clinic directors, seven who were clinic directors in one program said the average counselor caseload was 70 or more. In another program with two clinics, counselors had an average caseload of 45. All these nine clinics had large populations of clients on long-term maintenance who may have required less counseling time than clients in other programs. The directors of the other eight clinics reported caseloads of between 20 and 21 35 clients. Counselor reports corroborated the directors' perceptions. Thus, the counselor-client ratio in all clinics appears to be appropriate and well within the guidelines proposed by Lowinson and Millman and Woody and appears to provide sufficient time for weekly individual counseling sessions. Type of Counseling An average of 78 percent of clients said most or all of their counseling was MOnly about 7 percent reported receiving any group therapy or counseling, although in one clinic 53 percent of the clients said they receiv- ed an equal mix of group and individual counseling. In five clinics, about one-fourth of the clients said they had received no counseling of any kind during their first 3 months in treatment. All the clinic directors reported extensive use of individual therapy or coun- seling and scheduled individual sessions once a week or more often. Most of the clinics scheduled half-hour sessions. Three clinic directors reported sessions that lasted between 45 and 60 minutes. Counselors, on the other hand, reported that sessions lasted longer. One-fourth of the counselors reported that counseling sessions lasted an hour. Over half had sessions of 30-45 minutes. The remaining counselors averaged between 10 and 25 min- utes per session. According to the treatment directors, six clinics held group sessions less than once a week, and six clinics did not use them at all. In the four clinics with weekly group sessions, the length of the group was between 1% and 2 hours. In the other clinics, the sessions lasted from 30 to 60 minutes. This suggests that the clinics which have frequent groups use the technique intensively. Indeed, this was the case for two clinics that placed major emphasis on group therapy sessions. Still, individual counseling appears to be the backbone of most counseling in methadone treatment programs. Focus and Techniques Directors and counselors were asked about the major focus of the counseling and the techniques that Were used. Ten of the 16 directors who responded to this question said that practical problem—solving was the major focus. Two indicated that changing the client's life style was most important. Three others cited a variety of counseling goals. Only one focused on the physiological/medical aspects of methadone. Counselors had somewhat different orientations. Ten percent focused on the medical aspects, 40 percent emphasized day-to-day problem—solving, and 26 percent attempted to change the client's life style. All the clinic directors and counselors reported that individual, supportive counseling of many forms, including psychotherapy, was used extensively. Clinic directors reported that a moderate emphasis was placed on individual psychotherapy. Four others indicated there was some use of psychotherapy in their clinics. Forty percent of the counselors said they placed a major or moderate emphasis on individual psychotherapy in counseling sessions. Half of these counselors had advanced degrees. In 11 of the 17 clinics, either the director or the counselor indicated there was at least a moderate empha- sis on individual psychotherapy. Many staff reporting the use of psycho- therapy in their counseling also appeared to have advanced education. 22 Matching of Clients and Counselors Another aspect of counseling that has received little attention is the match of counselors and clients. Woody (1983) reported on types of therapy that may have differential effects. Though counselors have different strengths and use different therapeutic techniques, only 6 (35 percent) of the 17 clinic directors said they attempted to assign clients with particular kinds of problems to particular counselors. Most assignments appeared to be based on availability and counselor caseload rather than client needs. Another issue in the client/counselor relationship is the establishment of trust and rapport. A check of the TOPS clinic records revealed that three of every five clients had two or more primary counselors. In six clinics more than one-third of the clients had three or more counselors. On the other hand, in five clinics, more than half of the clients had only one pri- mary counselor. Unless counselor rotation is a planned approach to treat- ment, the continuity of the client/counselor relationship appears to be often disturbed; this warrants the attention of clinicians and researchers. The reasons for discontinuity and its effects on services and outcomes need to be explored more fully. More generally, clients were asked about their preference for group or individual counseling. Fifty-five percent of the clients said they thought the type of counseling they were receiving was "about right." An average of 31 percent, however, said they would prefer more individual counseling. Data from the 13 methadone clinics that participated in all 3 years of the study revealed a significant trend in the type of counseling preferred by clients (table 7). Over time, more clients said the type of counseling they received was "about right," and fewer clients expressed a preference for more individual counseling (x2 = 26.9, p <.001). It should be noted, how- ever, that there was also a trend toward greater use of individual counseling in TOPS methadone programs. TABLE 7 Trends in the Type of Counseling Preferred by Clients in Outpatient Methadone Programs Cohort Type of 1979 1980 1981 Counseling n=186 n=106 n=139 9 9 9 0 0 0 More individual 3 2 2 About right 5 5 6 More group More of both Less of both 01000509 «ion—nub COHNLOOO 0:inme NOONOOOO totbmubh- b—l 23 SERVICES In addition to counseling on drug abuse, clients may also receive services directed at specific problem areas. The need for a variety of ancillary and supportive services for methadone clients was first voiced by Dole et a1. (1968). Lowinson and Millman (1979) cited education, vocational rehabilita- tion, job placement, family therapy, and legal services as useful areas of specialization for counseling staff. In TOPS, information was obtained on seven different types of services distinct from drug abuse counseling: medical, psychological, family, voca- tional, educational, legal, and financial. Client self-reports, clinic records, and estimates of treatment directors all document that clients in methadone programs received a variety of services (see table 8). Details of each of these types of services are discussed in the following section. TABLE 8 Clients Receiving Various Types of Services in Outpatient Methadone Programs Based on Client Self-Reports, Clinic Records, and Estimates by Program Directors (1979-1981) Type of Service Psycho- Educa- Source Medical logical Family Legal tion Job Financial 9 9 9 9 9 9 9 Clients' Self- ° ° ° ° ° ° ° Reports (n=566) 35.3 16.1 10.2 3.6 5.9 8.5 4.9 Clinic Records (n=566) 68.1 32.9 9.4 7.5 9.1 16.5 12.7 Estimates by Treat- ment Directors (n=17) 42.0 20.0 12.0 12.0 15.0 10.0 20.0 Medical The issues concerning medical services in methadone treatment have been well documented (Kreek 1979; Lowinson and Millman 1979). Clearly, many clients need medical services beyond the intake physical. Fifteen of the TOPS clinics provided medical services in the program. Thirteen also refer- red clients to other health facilities. Four of these clinics had formal writ- ten referral agreements. One-third of the TOPS clients reported receiving medical services during the first 3 months of treatment. The clinical/medical records showed that about two-thirds of the clients received medical services. Part of the discrepancy may be due to the problem of differentiating the initial physical examination from other medical services. The most frequent medical service reported by clients was, indeed, a physi- cal examination (19 percent) or some unspecified treatment from a doctor or 24 nurse (15 percent). About 16 percent of the clients received a medical service once or twice during their first 3 months in treatment; another 12 percent received service one to three times per month during that period. Client records indicated 56 percent received physicals. Thirteen percent were referred to hospitals, and 23 percent had some type of general medical serv1ce. Unfortunately, the nature of the self-reports of medical services and clinic records makes it difficult to determine the character of those services. A more precise determination of the type, nature, and content of medical services may be important in understanding why the proportion of clients receiving medical services increased. In the trend analysis, 48 percent of 1981 clients reported receiving medical services in the first 3 months of treatment compared to 34 percent in 1979 (x2=9.5, p<.01). Clinical/medical records indicated an increase from 65 percent in 1979 to 87 percent in 1981 (x2=9.5, p<.01). Unfortunately we cannot determine if this increase was due solely to an increase in intake physicals or to the provision of more compre- hensive medical care. Psychological In the previous section on counseling, we discussed the increasing use of psychotherapy as an adjunct to drug counseling. Psychological services can be defined more broadly as any mental health or psychological services or help with emotional problems. Fourteen of 17 clinics provided such a ser- vice. Ten had referral arrangements; two had formal written agreements. Sixteen percent of clients said they received psychological services in the first 3 months of treatment. Clinic records indicated one-third had received such services. Again, there is a problem in differentiating psychological services from general drug abuse counseling. Clients indicated that individual therapy (14 percent) was the most common type of service received, usually once a week or less often. Clinic records showed 7 percent, had received psycho- logical testing, 9 percent group or individual therapy, and 6 percent referral to a mental health clinic. Some clinics also appear to be more oriented than others toward psychological services. In six clinics, both clinic records and client interviews indicated more than one-fourth of the clients received such services. In three other clinics, less than 10 percent of clients received these services. Analysis of the data from the client interviews at 3 months in treatment indicates trends toward fewer clients in 1981 (10 percent) than in 1979 (24.6 percent) receiving psychological services (x2=15.0, p<.01). In con- trast to the client interviews, clinic record data show a trend toward more clients in 1981 (36 percent) than in 1979 (21 percent) receiving psychological services (x2=8.2, p<.05). Despite the conflicting results from different data bases, it appears that many clients received help with their psychological problems, but the exact nature of this help and whether the availability and utilization of help were increasing or decreasing cannot be clearly determined from the TOPS data. 25 l f /. 'N Family Hall (1983) reviewed a number of studies of family therapy in methadone programs. She found that, although many programs had some form of family therapy focusing on the client and spouse or the family of the client, few forms of therapy had been evaluated. The study by Stanton and Todd (1981) indicated that family therapy could be beneficial. Woody (1983), however, cited major difficulties in gaining family participation in therapy for methadone clients. Fourteen of the 17 TOPS clinics had "services to help with family problems." Nine had referral arrangements, but only one of these was a formal agree- ment. Only about 1 in 10 clients received any help with family problems. No one clinic or group of clinics seems to ive strong emphasis to the family. The trends in both client interviews (x =18.7, p<.01) and clinic records (x2=8.5, p<.01) show less family therapy in 1981 than in 1979. Although working with families and scheduling sessions can be very difficult, some type of help with family problems is appropriate and useful for methadone clinics. \j Vocational Vocational services have long been advocated as important components of treatment (Wolkstein and Hastings-Black 1979). Clearly, the low rates of labor force participation and employment for most clinics support Hall’s views that vocational rehabilitation has an important place in methadone treatment. Hall goes on to say, however, that few clinics provide comprehensive ser- vices. Hubbard and Harwood (1981) found that high proportions (61—82 per- cent) of methadone clinics reported some type of vocational service. Less than 10 percent, however, had skill training. A third of the clinics had full-time vocational staff, and most provided service through referral. The situation in TOPS methadone clinics appeared somewhat improved. Seven clinic directors (41 percent) said they provided vocational or employ- ment services at the program. Fourteen (82 percent) had referral arrange- ments; five (29 percent) had formal written agreements. Ten (59 percent) of the 17 clinics had a vocational rehabilitation specialist. Despite these resources, only 1 in 10 clients appeared to receive vocational services. Only three clinics appeared to serve more than 20 percent of their clients. In most of the other clinics, less than 10 percent were provided vocational services. Thus, although the resources, either through staff or referral, were available, few clients appeared to receive services. One obstacle to effective service delivery may be the perception of the difficulties in finding jobs for clients in labor markets with extremely high unemployment rates. Staff may have felt that it was futile to make an effort when the [chance for payoff in jobs was so small. VEducational, Legal, and Financial Services Little information is available in the literature on the three other types of services: educational, legal, and financial. In general, few clients reported receiving these types of services, and clinic records did not indicate many clients were receiving help. Only nine of 17 clinics provided educational 26 services in the program, five provided legal help, and seven provided finan- cial help with housing, transportation, or referral to social service agencies. Client interviews and record checks indicated that less than one client in 10 got help in any one area. There were, however, three clinics where records indicated at least one of four clients got help with legal problems. In six of the 17 clinics, according to clinic records, over 25 percent of clients receiv— ed some kind of help with financial problems. Although these three problem areas can be important in the rehabilitation of clients, it is difficult to assess the nature and extent of services. In some clinics, because much of this help may be provided in the usual counseling sessions, it might not be identified by clients or records as a service. Number of Service Areas In order to assess the scope of services offered to clients, we looked at the@ number of the seven service areas each client reported and the number of . areas recorded in the client files. Just over half of the clients said they had rec 'ved a of se vice. The clinic records, however, indicated that over 80 percent received one or more kinds of services. No clear pattern of these services was found. The clients' self-reports of the number of different services they had receiv- ed during their first 3 months in treatment revealed no trend. The clinic records, however, indicated a trend toward clients’ receiving more types of services (see table 9). TABLE 9 Trends in the Number of Services Received by Clients in Outpatient Methadone Programs Cohort 1979 1980 1981 Variable n=186 n=106 n=139 9 9 9 0 0 0 Number of Services Received - Client Interviews None 44.4 62.1 45.8 1 29.5 11.3 28.8 2 or more 26.1 26.6 25.4 Number of Services Received - Clinic Records None 25.7 17.5 5.6 r7‘1 39.7 39.9 43.5 2 or more 34.6 42.6 50.9 Kw.» 27 There also appeared to be high and low service clinics in TOPS. In seven clinics more than 25 percent of the clients reported receiving services in two or more areas. In four other clinics, 60 percent of clients reported receiv- ing no services. Clinic records, however, revealed only 3 of 17 clinics where fewer than 25 percent of the clients received less than two types of services. In 10 clinics, more than 60 percent of the records indicated services in two or more areas. TREATMENT CONTEXT @he context of an inpatient program has been found to be an important . factor in its success (Moos 1974, 1975; Murdock et al. 1980; Penk and Rabinowitz 1978-1979). Little empirical evidence is available on these impor- tant intangibles in outpatient methadone programs (Hall 1983). Two features of programs may shed some light on the "style" of a program and its pos- sible effect on outcomes: (1) client participation and responsiveness and (2) clients' perceptions of treatment effectiveness. Directors reSponded to questions about their perceptions of clients' participa- tion in treatment. Nine of the 17 directors said participation in treatment activities was required only to some extent. In 11 clinics, clients were viewed as frequently keeping their counseling appointments and participating in clinic activities. Again, we see varying approaches to treatment. Repri- mands (7 directors) and loss of privileges (10 directors) were the most common methods of making clients conform to the rules and goals of the clinic. Clients were asked to rate several features of their treatment. In particular, the strictness of the rules and regulations, and helpfulness in reducing drug use and alleviating drug-related problems were rated. Clients also reported their level of general satisfaction with their treatment. Very few clients expressed dissatisfaction on any of these dimensions except for helpfulness with drug-related problems: 26 percent of the clients rated their treatment as "not at all helpful" with these problems. No appreciable differences among the cohorts were found in any of their ratings. Variation across clinics on many of the clients‘ ratings of their treatment was minimal to slight. Most clients were favorable in their assessments. Clients were generally less satisfied, and there was more variation among the clinics, with regard to the treatment's helpfulness with problems other than drug abuse. In four clinics more than half the clients said treatment was very helpful with such problems. However, in another four, more than half the clients said treatment was not at all helpful. We could find no clear correla- tion of attitudes with the numbers or types of services received. These attitudes may reflect a complex assessment of both the availability of services and the quality of services provided. PROGRAM COMPLETION AND AFTERCARE The length of treatment is positively correlated with treatment outcomes (Hubbard et a1. 1984, Simpson and Sells 1982). Most clients leave before completing treatment (Savage and Simpson 1978). The high readmission rates for drop-outs and program graduates may be essentially efforts of former clients who continue to have problems to extend the treatment period. 28 Aftercare or continuing care that provides additional services in the commu- nity (Brown and Ashery 1979) or encourages readmission when necessary has been advocated (D'Amanda 1983). In TOPS methadone clinics, about half the clients remained in treatment for 1 year or more. About 1 of every 10 clients was noted as completing treat- ment. Because the definitions of success are different, depending on philo- sophy and goals, we asked directors, "What percentage of clients...achieve these criteria for completion, maintenance, or graduation?" The responses ranged from 10 to 75 percent, probably reflecting more the critical problem of defining success in methadone treatment than actual program efficacy. Twelve of the 17 TOPS clinic directors reported that they frequently provid- ed aftercare services. When the records were checked for information re— garding followup or aftercare services, however, such services were noted for only about a third of the clients who had left treatment. In five clinics more than half of the discharged clients had received aftercare services. In five other clinics, none of the clients in the sample was identified as receiv- ing aftercare services. These results support the observation that aftercare services are not generally available to methadone clients. Especially consi- dering the propensity for clients to reenter treatment, more aftercare services are clearly needed. Studies of effectiveness of available services are also necessary to demonstrate the. benefits of providing aftercare ser- Vices. Methadone programs have clearly changed over the past decade. The emphasis on methadone-to-abstinence and the emphasis on long-term mainte- nance now appear to be about equal and more counselors are professionally trained. The major characteristics of treatment in the 17 TOPS methadone clinics appear to be to The clinics were large (over 200 clients); free standing; and in urban areas. Their budgets were publicly funded at about $2,000 per client slot. 0 Staff members were experienced. Sixty percent had at least a bachelor's degree, and many had either a medical or social rehabili- tation background, depending on the clinic. 0 Diverse opinions about maintenance and abstinence and treatment goals existed, even within the same clinic. 0 Many clients were self-referred and had previous treatment experi- ence (many transferred from other programs). Larger clinics tended to have larger minority populations with lower education levels. 0 Clients reported a variety of problems, often drug-related family problems and depression. Different clinics saw clients with differ- ent arrays of problems. Drug-related medical problems appeared to be increasing, while family problems were decreasing. 29 Clients were not aware of treatment plans, although signed plans were found in most client files. This suggests that clients should become more involved in the preparation of their plans and the review of their progress. Methadone dosage levels after 3 months in treatment were low (usually 20-70 mg/day). A trend toward lower dosage levels was found. Take-home privileges were common, but clinics differed widely in the proportion of clients with take-homes privileges. Counselor caseloads of 20 to 35 were reported in most clinics. In clinics with more long-term maintenance clients, caseloads were higher. Individual counseling was the norm. Individual psycho- therapy was reportedly used, at least to some extent, in 12 of the 17 TOPS clinics. Most clients (60 percent) also had two or more primary counselors during treatment, suggesting the need for guarantees of counselor consistency. Except for medical services, few clients reported services distinct from drug counseling. More family, vocational, and psychological services appear to be needed in most clinics. Clients were satisfied with their treatment for drug abuse. There was generally less satisfaction with help for other problems. Although programs reported aftercare services were available, only about one-third of the clinic records for terminated clients indicat- ed any aftercare had been provided. 30 3. DRUG FREE RESIDENTIAL AND THERAPEUTIC COMMUNITIES Synanon, begun in 1958 by Charles Dederich, was the first therapeutic community (TC) established for the treatment of drug abusers. It grew out of and was loosely based on the philosophical principles of Alcoholics Anony- mous (Glaser 1974; Yablonsky 1965). Other therapeutic communities (e.g., Daytop Village in 1963; Phoenix House in 1967; Odyssey House in 1966; Gateway Foundation in 1968) were developed during the 19605 based on the Synanon concept. In these TCs, unlike Synanon, reentry or return to society was a major goal (Brook and Whitehead 1980). Within a few years, considerable anecdotal evidence of the success of the TC approach had accumulated, and by 1979 over 300 therapeutic communities had been estab- lished across the country (DeLeon and Rosenthal 1979). In 1982, about 1 in 10 treatment clients were residents in therapeutic communities or similar 24-hour live-in facilities (National Institute on Drug Abuse 1983). A basic goal of the TC philosophy is for drug abusers to undergo a "com- plete change in lifestyle: abstinence from drugs, elimination of antisocial (criminal) behavior, development of employable skills, self-reliance, and personal honesty." To effect this change requires a "total 24 hour com- munity impact" (DeLeon and Rosenthal 1979, p. 40). Briefly, all TCs emphasize a self-help approach and rely heavily on the use of ex-addicts as peer counselors, administrators, and role models. The atmosphere in the programs is highly structured, especially for newer mem- bers, with nearly every moment accounted for. Members progress through the program in stages which are usually clearly demarcated. Each succeed- ing stage carries more responsibility (and in some programs, more personal freedom) than the previous one. Group counseling or therapy sessions, which are usually confrontive in nature and stress openness and honesty, are a cornerstone of the TC approach to treatment. Indeed, the name Synanon is reputed to have come from a client's mispronunciation of the word "seminar" which is what Dederich called his early group meetings (Yablonsky 1965). All members are assigned to some kind of work duties with the level of responsibility determined by the member's position in the community. In addition, members who are more advanced in the program may be employed or enrolled in school or job training classes outside the community. Some TCs provide educational programs within the community (Bookbinder 1975). 31 A number of authors (e.g., Densen-Gerber 1972; Nash 1974; Yablonsky 1965) have written detailed and readable accounts of life in a therapeutic community. In addition, Kajdan and Senay (1976) wrote brief overviews of the treatment programs in Synanon, Odyssey House, Phoenix House, Gateway House, Safari House, Tinley Park, and a number of other therapeutic com- munities, especially as they relate to youthful addicts. More recently, Holland (1982) conducted a survey of characteristics of 32 long-term (12 months or more) residential programs that included information on program goals and treatment process in these clinics. One problem outlined by the Therapeutic Communities of America Planning Conference was the need for a definition and codification of concepts and factors essential for the success of TCs (DeLeon and Beschner 1976). DeLeon and Rosenthal (1979) echoed this need in their call for studies of why TCs work, including studies of treatment process and effective elements of a program. The essential dynamic process of the TC as a total community structure makes the identification and analysis of component parts or elements a formi- dable challenge. No one element can be understood in isolation. The follow- ing sections attempt to identify a number of basic elements of TCs as a first step in moving toward a more complete understanding of the dynamic process of the TC. This analysis includes 14 TOPS residential facilities. Unfortu- nately, one program with three residences did not participate in the study in 1980 and 1981. Because the director and staff of the three houses had changed, no director or counselor information was collected. Three other houses did not provide complete data to NDATUS. Thus, the interview and clinical/medical data were available for all 14 residences, while director and counselor information was available for only 11 residences and NDATUS information for another 11. SIZE AND STRUCTURE Like most TCs, the 14 TOPS residential facilities were all free-standing units of limited capacity. Most were independent houses operating through con- tracts with State or local agencies. Three facilities were part of one large TC with residences throughout the State, and two were part of another. The average capacity of the TOPS facilities was 64, compared to only 31 for the 379 single modality units reporting to NDATUS (National Institute on Drug Abuse 1983). Clinics in TOPS ranged from 26 beds to 126 beds. With two exceptions, the houses were located in urban areas close to addict populations . The average annual cost per bed for 12 of the 14 TOPS residences in 1980 was $6,135. This is somewhat under the average cost of $7,329 per bed for residences reporting towns in 1982. It is also considerably under the $25 per day median client cost for long-term programs analyzed by Holland (1982). The lower per bed costs of TOPS residences may be due to the larger sizes of the facilities, because fixed costs such as rent, administrative staff, and utilities are distributed over a larger number of clients. Indeed, the highest per bed costs in TOPS, $9,038 and $8,372, were found in the two smallest residences. 32 To see changes in budgets over time, NDATUS financial data were examined. NDATUS reports show that costs per client in all residential programs have risen from $4,920 in 1976 to $7,329 in 1982. It appears that residential programs in general have kept their cost increases (49 percent) under the general rate of inflation (63 percent) for the same period. How they accom- plished this and the impact of cost control on services is not known. All 12 of the clinics with available funding data had NIDA statewide services contracts. Ten had State funding and two local government funding. Four received some private donations. Nine received support from public welfare and five had revenue from client fees. Other sources included Bureau of Prisons (4), Law Enforcement Assistance Administration (LEAA) (l), and CETA (3). Most of the residential programs clearly received a large propor- tion of their financial support from public funds. STAFF The staff of T05 is seen as one key to the program's success. DeLeon and Rosenthal describe the staff of most TCs. The primary staff are nondegreed professionals. As former offend- ers, addicts and alcohol abusers, who themselves have been reha- bilitated in therapeutic community programs, they serve in both clinical and custodial roles. Degreed professionals in vocational guidance, education, medicine, mental health, legal and fiscal administration, and research also comprise the staff of larger TCs (DeLeon and Rosenthal 1979, p. 39). The use of ex-addict staff is fundamental to the concept of TCs. However, studies of the impact of ex-addict versus nonaddict professional counselors have been limited. Holland (1982) reported that about 40 percent of staff in 32 long—term residential programs were recovered substance abusers. Nash (1978) found less improvement in arrest rates in clinics with a higher ratio of ex-addicts and more staff with 12 months or more experience in the pro- gram. For all residential NDATUS programs in 1979 and 1982 (see table 10). about two-thirds of the full-time hours were for nonmedical direct service. The proportion of hours for physicians and nurses was less than 5 percent. Little change seems to have occurred over these years. In the TOPS residences, the patterns of staff hours were similar. All 11 houses with NDATUS data had over half their staff hours devoted to direct services. Most of the staff were nondegreed counselors. Nine of the 11 clinics providing staffing data, however, had at least one counselor with a bachelor's degree. The interviews with directors and counselors who had been with the program for at least a year revealed a high level of training. Over half of the 18 counselors were college graduates; five had master's degrees. Eleven had at least 5 years of work with drug treatment programs; nine worked all of their years with their current program. 33 TABLE 10 Percentage of Hours Worked by Different Types of Staff in NDATUS Residential Programs in 1979 and 1982 1979 1982 Physicians 0 . 8% 0 . 7% Psychologists 3.0 3. 3 Nurses/Medical 2.9 3.3 Social Workers 5.1 2.9 Counselors 53.0 51 .8 Bachelor's Degree 15.9% N/A Associate's Degree 3.8 N/A Nondegreed 33.3 N/A Other Direct Services 4.3 13.6 Administrative/Support 31.0 24 .4 All Staff 100.0% 100.0% n=3021 n=3804 Ex-addict status of counselors was not determined. While all counselors re- ported that ex-addicts were used in counseling to a great extent, directors of two residences indicated that ex-addicts were used only to some extent in direct counseling. The staffs of residential programs appeared still to have a very strong ex-addict component. However, there is also evidence that the level of formal staff training was rising. This may be a result both of upgrading the education of current staff and recruiting professional staff. The five counselors with master's degrees had between 2 and 6 years' experi- ence in drug treatment. Three of the four counselors with bachelor's degrees had over 10 years' work experience in drug treatment; the other had close to 7 years. While the residential programs maintain their strong orientation to the ex-addict staff model, the importance of formal education and professional training of staff appears to be increasing. In the mid-19705 the coordination of professional and paraprofessional roles was seen as potentially a major internal problem in the therapeutic community (Brook and Whitehead 1980; DeLeon and Beschner 1976). The limited job experience of most ex-addict counselors was also viewed as' a a major ob- stacle to clients successfully reentering the community (Brown 1979; Brown and Ashery 1979). This reconciliation of professionals and paraprofessionals appears to be proceeding successfully. The goal of incorporating formal training with experiential backgrounds advocated in the 1976 TCA policy conference now seems attainable. The accomplishment of this integration and its impact on the TC philosophy and process, as well as outcomes, warrants considerable attention and detailed analysis. 34 APPROACHES AND GOALS Therapeutic communities and most residential programs have generally con- sistent philosophies and approaches. The fundamental goal is to change dysfunctional behavior to an effective and productive lifestyle. The main elements are ' a long—term intensive communal experience, ' group therapy supplemented with other appropriate services and activities, - a major therapeutic role for paraprofessionals who have had experiences similar to those of residents, and a commitment to reenter those of the larger society through the TC subculture. Although advocates of TCs have differed on these and other aspects of the therapeutic community movement, there is general consensus on the goals and approaches. The fundamental problem for TCs involves how to maintain these goals and approaches as they interact with the general health care system and Federal, State, and local bureaucracies (DeLeon and Beschner 1976). In addition to the problem of professional versus paraprofessional staff, discussed above, three other controversial issues were fundamental in the approach of residential programs: resocialization, duration of treatment, and reentry. Resocialization Two beliefs about drug abuse form the basis for the general goals of the therapeutic community. One is that addiction cannot be cured but can only be put in remission by reliance on self—help and support by other addicts (Yablonsky 1965). However, proponents of therapeutic communities, such as DeLeon and Rosenthal (1979), feel that drug use is not a recurrent or chronic disease but a behavior that can and should be completely eliminated. Cole and James (1975) identified three approaches W, each with a somewhat different orientation toward resocialization. The tradi- tional TC goals were to achieve changes in the addict's value system and lifestyle, to help the client develop self-control, and to return the addict to unsupervised community living as a self-sufficient, effectively functioning member of society. The modified TC had more limited goals, to aid the addict in attaining a drug free state and to develop practical skills and tools to enable the individual to sustain her/himself in society. Expectations of total resocialization are usually regarded as overambitious. Short-term residential programs appeared not to emphasize resocialization. Their goals were to assist the addict in eliminating drug use, to reestablish family rela- tionships, and to provide the addict with skills to enable her/him to survive in the environment without resorting to criminal activity. 35 Holland (1982) also found that the goals of programs with three lengths of planned durations for treatment seemed to support the Cole and James frame- work. Longer term programs were much more likely to have both residential and reentry phases. This implies a more complete commitment to preparing the resident to function in society after treatment. Longer term programs also had higher expectations that clients would avoid criminal activities, have positive relations with others, and function without the aid of support groups. In the DARP study in the early 19705, residential programs were evenly divided among the three types. In TOPS, on the other hand, only three residential facilities described themselves as modified programs. Only one of these, however, indicated that resocialization was not its major focus. Thus, it appears that the residential programs in TOPS have a philosophy of resocialization similar to that of traditional TCs. Duration of Treatment DeLeon and Rosenthal (1979) described traditional TCs as requiring at least 15 months in residence for graduation. Cole and James (1975) had a similar definition of a traditional approach to the TC. The modified TC had only a 6-9 month requirement and the short-term TC 3-6 months. Information on planned duration of treatment obtained by Holland (1982) from 556 of 884 nonhospital programs indicated that 35 percent were short term (less than 6 months), 28 percent middle term (6-11 months), 25 percent long term (a year or more), and the remaining 12 percent had multiple options. These data seem to support the DeLeon and Rosenthal observation that more residential programs are experimenting with shorter treatment. The TOPS data also support this View. Although 9 of the 14 residential programs reported a planned duration of 12 months for most clients, four had planned durations of 10 to 12 months, and one required less than 4 months in resi- dence. Only one residence indicated a planned duration for most clients of 18 months or more. Cost, availability of beds, requirements to serve more clients, and accredita- tion for health insurance reimbursement make duration of treatment a key issue. Where previously most TCs adopted a standard treatment duration, the movement now seems to be toward more flexible plans. As Holland correctly points out, different treatment durations, staff compositions, and client populations may require very different treatment processes. Firm evidence of the impact of duration on outcomes is needed before shorter term residential treatment can be confidently recommended. Reentering the Community A major problem with shorter treatment duration is that the reentry phase must be compressed or eliminated. Holland (1982) found that only one in five short-term programs had both residential and reentry phases compared to 76 percent of the mid-term programs and 94 percent of the long-term programs. 36 Reentry‘has been and continues to be an issue of considerable importance and controversy. Although Synanon originally viewed graduation from the program and reentry into society as an "achievable goal" (Yablonsky 1965), the leadership of Synanon reexamined this goal and concluded that a com- plete reintegration with "straight" society was not possible for the vast majority of addicts (Brecher 1972). Other TCs based on the Synanon con- cept, such as Daytop and Phoenix House, maintained that reintegration was possible and desirable. Even in those programs whose stated aim is such reintegration, graduates of TCs often go on to assume responsible positions in their own or another TC program. Johnson (1976) suggests that the very nature of the TC approach may create the professional ex-addict, graduated from the TC but still not a part of "straight" society. Bookbinder (1975) speculates that the label "ex-addict" stigmatizes graduates and makes employment in a TC much more meaningful and satisfying than jobs outside the TC. Bourne and Ramsey (1975) suggest that TCs breed dependence on the peer group in the course of treatment by denying individuality and emphasizing group processes. Brown (1979) and Brown and Ashery (1979) outline some of the potential problems in having ex-addicts responsible for preparing other clients for reentry into the community outside the TCs. Ex-addicts have their own adjustment problems which may interfere with their effectiveness. In the TOPS residential facilities that encourage long residences, great emphasis is placed on formally designated phases. Seven of the nine resi- dences with a planned duration of 12 months or more reported that designa— ted phases were used. Three of the five residences with shorter planned duration reported little reliance on the use of phases. Although no direct question on reentry was asked, the TOPS data seem to support the findings of Holland (1982) and the concepts of Cole and James (1975). There is less emphasis on phases (probably including reentry) and resocialization in residences where there is a shorter planned duration of treatment. The difference in philosophy, goals, and approaches of programs with different durations could significantly affect treatment outcomes. It seems much might be lost, especially in preparation for reentry, if the duration of residential treatment is reduced dramatically. Assessing the optimal time in residential treatment and the reentry process is a complex task that should be undertaken with a detailed knowledge of client character- istics and the treatment process in residential programs. CLIENT CHARACTERISTICS Residential programs serve a clientele with a broad range of problems: adolescent drug abusers, court-referred offenders, multiple substance abus- ers, and the socially dislocated. WWWdfi/ Wual differences such as drug use patterns, criminal justice involvem , sex, ethnicity, and prior treatment experience as they relate to retention and outcome. 37 Drug Use The diverse client population entering residential treatment evolved from an early emphasis on adult heroin addicts (DeLeon and Beschner 1976). One early study (Glasscote et a1. 1972) noted with concern the trend to mix heroin addicts and users of "lesser" drugs., Freudenberger (1976) observed that the addicts who came to TCs in the early 19705 were younger and more likely to be polydrug abusers than was the case in the early 19605. Clients in TOPS residential treatment programs had a wide variety of drug use patterns in the year prior to treatment. Thirteen percent used heroin and other opiates as well as a variety of other drugs; 23 percent used heroin (but not other opiates); 18 percent used other opiates (but not heroin). These three opiate use categories accounted for over half of the clients. Multiple nonnarcotic use was typical for 10 percent of residents. An additional 17 percent fell into the single nonnarcotic use group, and 12 percent were classed as primarily alcohol and/or marijuana users. An- other 7 percent did not report weekly drug use in the year prior to treat- ment. Based on the clients' self-reports of the quantity and frequency of their alcohol consumption, about one—fourth of them were classed as heavy drinkers. It appears that residential programs are, indeed, attracting polydrug abusers. There were also fewer heroin users in TOPS residential programs in 1981 (32 percent) than in 1979 (45 percent). The difference was also seen in more nonnarcotic users in 1981 (30 percent) than in 1979 (20 percent). The trend toward treating more multiple substance abusers and fewer heroin users appears to be continuing. There were major differences among the residences. In five facilities, over half the residents were heroin users. In four other facilities, less than 15 percent of the clients used heroin weekly or more often in the year prior to treatment. Thus, although we saw a general trend toward more polydrug users entering residential programs, a number of facilities still have a major focus on heroin addicts. Clearly, different types of outcomes might be expected from programs with different mixes of drug use patterns. Female Residents DeLeon and Beschner (1976) cited the difficulties in providing services to women residents and their lower retention rates. Freudenberger recom- mended that more women be appointed to staff positions and suggested that staff be more sensitive to the needs of women clients. Levy and Broudy (1975) found that women were viewed by both staff and clients as more dependent, more emotional, and sicker than men. They also found job assignment and job training practices followed a stereotyped view of the sexes. Finnegan (1979) and Beschner and Thompson (1981) outlined some of the special needs of women in treatment for drug abuse, especially medical and family services and self-esteem support. At one time it was thought that more females would be entering TCs and there was concern that their special needs would be unmet. About one out of five TOPS residential clients was female. This percentage has not chang- ed much since the early 19705. There was: a somewhat higher proportion of females in TOPS treatment in 1981 (27 percent) than in 1979 (14 percent). Perhaps efforts to provide services for females had, indeed, resulted in better recruitment and retention of female clients. Although none of the TOPS facilities was designed especially for women, in four facilities at least one-third of the residents were female. Three other residences had few women (less than 10 percent). Thus, it appears that some programs are oriented toward women while some others still focus mainly on male clients. Ethnicity Reconciling the culture of the TC with ethnic values and mores has also been of concern (DeLeon and Beschner 1976). Early views of TCs saw the clients as predominantly middle class (Glasscote et al. 1972). Residences established later, such as Phoenix House, were located in urban areas, where minority clients were more likely to apply. One result was great differences in the racial compositions of clients and staff within some programs (Collier and Hijazi 1973). Freudenberger (1975) suggested that TCs modify their treat- ment programs to fit the needs of clients underrepresented in the TC popula- tions such as Asians and Native Americans. He even suggested separate facilities for Hispanics due to language and cultural differences if their numbers warrant such facilities. Most residential programs now appear to be successfully assimilating minority clients. Just over half of the TOPS residential clients were white, and 40 percent were black. Only three of the facilities could be considered predominantly white. Two houses had over 85 percent black clients. In four residences there were about equal numbers of whites and blacks. In three residences at least 10 percent of the clients remaining in treatment at least 3 months were Hispanics. Thus, though the residential modality ap- pears to be able to attract few Hispanic clients, some facilities can attract and retain them. Age No trend was found toward younger or older clients entering residential programs. None of the TOPS facilities was oriented specifically toward youth. Five of the residences had at least 20 percent of residents under 21; two of these had about 40 percent. In seven other residences less than 10 percent of the residents were under 21. Young clients were not a major segment of the population of most residential programs. Legal Involvement The largest single source of referral among TOPS residential clients (40 per- cent) was the criminal justice system. Another 40 percent were referred by themselves or by family or friends. About 25 percent of clients lived in some kind of institutional setting, mainly jail, at the time they were admitted to TOPS residential treatment. Roughly two-thirds of the clients had some involvement in the criminal justice system at the time they were admitted to, treatment; well over half of these clients were on probation or parole. A trend away from self-referrals and toward more referrals by family or friends or by the legal system was observed from 1979 to 1981. Also, a shift in the clients' legal status was observed (x2 = 40.2, p<.001). Fewer clients were 39 involved with the criminal justice system but, of those who were, more were on probation or parole and fewer were in jails or prisons at the time they were admitted to treatment (table 11). TABLE 11 Trends in Referral Source and Legal System Status in Residential Programs Cohort 1979 1980 1981 Variable n=65 n=71 n=56 9 9 9 O 0 O Referral Source - From Client Self-Reports Self 21.4 17.6 10.4 Family/Friends 16.3 12. 0 22. 7 Legal System 40.3 36.2 45.8 Other 22.0 34.2 21.1 Referral Source - From Clinic Records Self 35.2 25.4 13.0 Family/Friends 12.0 8.7 8.9 Legal System 36.3 36.6 55.2 Other 16.5 29.3 22.9 Legal System Status None 26.3 33.2 40.5 Probation/parole 23 .0 43 .5 41.9 Bail 7.9 6.5 7.7 Jail/prison 37.9 16.8 9.8 Other 4.9 0.0 0.0 A number of facilities seemed to focus on criminal justice system clients. In six facilities, three of every four clients were involved with the criminal justice system. In another four facilities, about two-thirds of the residents were involved. Only four clinics did not have a majority of clients involved with the criminal justice system. Clearly, all programs could benefit from information on providing effective services to criminally involved clients. Prior Treatment Well over half the TOPS residential clients had been treated previously for drug abuse, and over one-fourth had more than one treatment episode. Those who had been in just one type (or modality) of prior treatment consti- tuted only about 27 percent of all residential clients and about half of resi- dential clients who had any prior treatment for drug abuse. 40 More clients in the 1980 cohort (63 percent) had previous treatment for drug abuse than those in the 1979 or 1981 cohort (54 and 53 percent, respec— tively). Of those who had previous treatment, 53 percent had treatment in more than one modality. An examination of the modalities experienced by clients who had been in only one type of treatment reveals a complex trend. Nearly half (48 percent) of previously treated clients from the 1979 cohort had been in residential treat- ment, 3] percent had been in methadone maintenance, another 10 percent each had been in detoxification and outpatient drug free (OPDF) programs. In the 1980 cohort, 39 percent had been in residential treatment, 11 percent had been in methadone treatment, and 22 percent each had been in detoxifi- cation and OPDF programs. Corresponding figures for the 1981 cohort are 23 percent (residential), 14 percent (methadone maintenance), 17 percent (detoxification), and 26 percent (OPDF). Thus, residential programs obtain- ed an increasing proportion of intakes from detoxification or OPDF programs and a dramatically decreasing proportion from residential treatment. PROBLEMS AND SERVICE NEEDS The diverse client population served by residential programs indicates a wide range of problems must be dealt with (DeLeon and Rosenthal 1979). Needs of special populations such as women, court-referred clients, and multiple substance abusers have been a topic of considerable concern to the thera- peutic community (DeLeon and Beschner 1976). The data from TOPS indicate that the concerns about the multiplicity of problems among residential clients are warranted. Problems were examined using data from the client interviews at intake and at 3 months in treatment as well as information taken from the clinical records. It should again be noted that these were the problems of clients who remained in treatment for at least 3 months. Clients staying for shorter periods may have more, different, or fewer problems. Nature of Problems Clients were asked whether their drug use had caused them any medical, mental health, family, legal, employment/school, or financial problems during the year before admission to treatment. An average of 14 percent reported no such drug-related problems; 15 percent, one or two problems; 38 per- cent, three or four problems; and 32 percent, five or six problems. Table 12 shows the percentages of clients who reported various problems at intake, who were noted by clinic staff as having problems, or who felt they needed services for various kinds of problems. In the TOPS intake interviews, family problems were mentioned by more clients than any other type of problem. The clients' presenting complaints were drawn from the clinic records. Drugs were mentioned in 65 percent of the cases. The second most frequently mentioned complaint was psychological problems (16 percent). The clinic records, particularly the counselors' casenotes, provided informa- tion on the staff's view of the clients' problems. Medical and psychological problems were noted for 39 and 36 percent of the clients, respectively. Other types of problems were noted in 3 to 24 percent of the case files. In 41 the TOPS interviews after 3 months in treatment, clients were asked the types of problems for which they needed services. Remarkably large per- centages of clients expressed a need for services in nearly all areas. Medi- cal and educational services were mentioned by over 70 percent of the cli- ents; psychological, financial, employment, and family services were men- tioned by about half the residents. Clearly, both clients and treatment staff View the clients as having problems in a number of different areas. The low percentages of records containing notations of these complaints may suggest that the clients are not informing the programs of all their problems. TABLE 12 Problems Presented at Admission and During Treatment in Residential Programs (n=422) Type of Problem Psycho- Educa- Medical logical Family Legal tion Job Financial 9 9 9 9 9 9 9 0 0 0 0 0 0 0 Client Self—Reports of Drug-Related Problems at Admission 46.4 54.5 71.8 54.4 49.6 59.9 Presenting Complainta as Noted in Clinic Records 4.6 16.4 2.7 8.8 - 4.7 3.0 Problems Quring Treatment as Noted in Clinic Records 39.0 36.3 24.3 15.7 11.9 11.7 2.6 Clients' Perceived Need for Services After 3 Months in Treatment 75.4 62.4 55.8 34.6 70.1 58.8 60.4 aComplaint/problem other than drug abuse. Mental health seems to be a particularly critical problem among clients enter- ing residential treatment (DeLeon 1984; Zuckerman et a1. 1975). During the TOPS intake interview, clients were asked whether they had felt so depress- ed they could not get out of bed at any time during the year before admis- sion, or whether they had thought of suicide or attempted suicide during that time. Sixty percent of the TOPS residential clients responded "yes" to one or more of those questions, and 13 percent reported at least one suicide attempt. The diagnosis and treatment of depression and other mental health problems should be a concern for residential programs. 42 Trends The data on client problems across the three annual cohorts were analyzed for differences which might suggest trends. Only the facilities which parti- cipated in all 3 years of the TOPS were included in these analyses. Al- though some minor fluctuations were observed, no trends were evident in the number of different problem areas mentioned by clients either at admission or at 3 months in treatment. Similarly, there were no trends in the percentages of clients reporting specific types of problems at either of these times. The single exception to this finding is that psychological problems were reported at admission by fewer clients (x2 = 6.6, p <.05) over time. The three cohorts were not different with respect to indicators of depression. . A consistent downward trend is evident in the clients' perceived need for services: fewer clients in 1981 expressed a need for services in all cate- gories except legal services. The trend toward less need is most pronounc- ed in the need for medical services. TREATMENT PLAN AND PROCESS As in other types of programs, treatment plans were required and had to be updated every 30 days. Without exception, the TOPS residential treatment directors stated that individualized, formal treatment plans were prepared for all clients in their clinics. Most clinics prepared plans within a week after the client entered the program. Indeed, 98 percent of the client files con- tained such plans signed by the clients. In stark contrast, nearly two- thirds of the clients said they had not received such a treatment plan, even though most counselors and directors reported that clients were involved to a great extent in the preparation of their plans. It may be that the plans were signed along with other documents and, therefore, the clients failed to notice or remember them. In only two residences were most clients reported to be involved to "some extent" in the development of their plans. Giving residents a clearer picture of the goals and requirements of treatment, and perhaps, more involvement in the development of their plans might increase program retention rates. Yablonsky (1965) provided an excellent description of the classic therapeutic community. Entry into the program requires a rigorous review to determine readiness to become a member of the community. Once accepted, the new member has little responsibility and performs basic housekeeping chores. As residents progress through treatment, they gain more responsibility and privileges. Most traditional TCs divide treatment into phases. Holland (1982) identified these phases as residence, reentry, and aftercare. As previously discuss- ed, most of the TOPS residences exerted control over all phases of treat- ment. Another key component of the treatment process is the initial trial period for enrollment. Brook and Whitehead (1980) observed that the usual admission procedures originally involved a test of a prospective resident's motivation to enroll in the program. Court referrals, however, appeared to reduce the importance of this process. 43 Three of the TOPS residences admitted clients within the first few days after application. The other residences typically required at least a l- to 2-week trial period. The high dropout rate for TCs suggests that even this process cannot easily identify applicants who will remain in treatment. This trial phase is one area that might warrant further investigation to develop more accurate methods of assessing an applicant's motivation and ability to com- plete the program. COUNSELING The 24-hour community experience is the fundamental aspect of residential programs (DeLeon and Beschner 1976). Within this experience, encounter groups, individual therapy, educational sessions, and residential job func- tions provide the elements of the therapeutic process. Glasscote et a1. (1972) described the treatment process as a combination of psychodynamics (group transactions) and behavior modification (illustrated by the system of privileges and sanctions). Critics contend that therapeutic communities need to broaden their ap- proaches and become more flexible (Deitch and Zweben 1976). Coulson (1975-1976) recommended the replacement of confrontive therapy techniques with more constructive methods including positive reinforcement. Glasscote et a1. were concerned about the "demeaning and punitive" approach to resi- dents. DeLeon and Beschner (1976) reported concern at the TCA planning conference about the impact of the confrontational approach for younger residents. The following sections examine some aspects of these therapeutic elements of TCs. Type of Counseling Individual and group counseling is the focus of most of the therapeutic effect in residential programs. Brook and Whitehead (1980) found that clients in the major TC programs spent about 3 hours a day in therapy of some kind. Holland (1982) reported about 12 hours per week in treatment activities (group or individual counseling), 13 hours per week in reentry activities (vocational counseling and use of community resources), and 8.5 hours in interpersonal activities. These two studies focused on different aspects of therapy: Holland on activities and Brook and Whitehead on pro- cess. Both recommended that extensive time be spent on direct therapy. In TOPS, directors and clients were asked about the type of counseling provided in the residence. By far the most frequently received type of counseling was "mostly group"; nearly 60 percent of the clients gave this response. Only 10 percent reported receiving all or mostly individual coun- seling. All but one residence provided group counseling at least twice a week. Four of the 11 reporting directors scheduled sessions four or more times a week. Session length varied from 90 minutes in three residences to 3 hours in two others. The remaining six had 2-hour sessions. Individual counseling was available in all 11 TOPS residences for which director and counselor information was obtained. All but one of the 11 facilities offered individual counseling at least once a week. Four residences had sessions more than once a week. Most of the sessions were 45-60 min- utes. In two facilities, however, sessions were only 15-20 minutes, though 44 these sessions were scheduled more than once a week. Counselor caseloads were all less than 15. The different proportions of group and individual counseling may have different effects on outcomes. About one-fourth of the residents received at least half their counseling in individual settings. About one in 10 clients reported receiving mostly individual counseling. In six residences at least one-third of the clients received at least half their counseling as individual therapy. In three other residences most of the clients indicated that individ- ual counseling was a major approach. Overall, 55 percent of the clients expressed a desire for more individual counseling, and 18 percent said they would prefer more group counseling. Over the 3 years of TOPS, however, the proportion of clients reporting re- ceiving more individual than group counseling declined from 29 percent in 1979 to 14 percent in 1981 (x2 = 7.1, p<.05). The results of the TOPS analyses indicate that counseling in TCs has ex- panded beyond the primary reliance on group encounters. As DeLeon and Rosenthal (1979) indicated, the TC regimen includes a wide array of services and techniques. The inclusion of individual counseling may allow TCs to address in more detail the specific'problems of new types of clients entering the programs (DeLeon and Beschner 1976). In fact, 6 of the 11 reporting directors indicated that extensive attempts were made to match clients with counselors. Focus and Techniques As might be expected, both directors and counselors in the TOPS residential programs placed at least a moderate emphasis on all types of group therapies including sensitivity, encounter, and task-oriented or problem-solving thera- pies. Also, as expected, the individual sessions had a strong orientation toward social support and behavior modification. What was surprising, however, was the report that in five residences there was at least a moder- ate emphasis on individual psychotherapy using traditional techniques. This’ seems to follow the view expressed at the TCA planning conference that TCs should adopt effective approaches from other clinical models (DeLeon and Beschner 1976). The directors and counselors all strongly emphasized all areas of well-being, including physical health, coping skills, social functioning, self-esteem, self-understanding, and abstinence from drugs. When asked to rank these six goals for the programs, marked differences in views emerged regarding the importance of abstinence from drugs (mean rank 2.3). Eight programs ranked abstinence as the most important goal; three ranked .it as one of the least important. Physical health (4.5) and social functioning (4.7) were ranked as the least important goals. Self-understanding (2.5), self-esteem (2.9), and coping skills (3.8) were rated as the middle three goals. This ranking conforms to the stated philosophy of most TCs: a commitment to help residents to gain self-understanding and self-esteem. The ambivalence toward the use of illicit drugs is perplexing, given the strong stance taken by TCs against any use of drugs. The low ranking by the three residences would seem to indicate only that other goals were given more importance. 45 Sanction and Privileges The use of privileges and sanctions is a fundamental method of motivating behavior through the stages of TC experience (Brook and Whitehead 1980; Glasscote et a1. 1972). Holland (1982), in comparing short—, medium-, and long-term traditional TCs found that long-term TCs are more likely to use sanctions and privileges, and to emphasize peer responsibility for explaining, clarifying, and giving feedback on behavior. All of the TOPS programs used some kind of loss of privilege as a sanction. However, two only used it "to some extent." Verbal reprimands were not used or used only to "some extent" in three residences. As expected, the most common form of influence was peer pressure. It was used to a great extent in 5 of the 11 facilities and to some extent in the others. Despite the strict, nonpermissive structure of most programs, two-thirds of clients felt the rules and regulations were about right and only 13 percent felt they were too strict. More than 1 of every 4 residents felt the rules were too strict in only 5 of the 14 facilities All programs reported that the violation of program rules and regulations was an important reason for the dismissal of clients. In four programs, use of illicit drugs was only somewhat important as a reason for dismissal. Clearly the TOPS residential programs were typically nonpermissive. They did, however, differ in the nature and extent of their use of sanction and privileges. As Holland suggests, subtle variation in the approach to treat- ment may have important impacts on other aspects of treatment process and on outcomes. SERVICES DeLeon and Rosenthal (1979) listed a variety of activities in addition to ther- apy that are included in the TC regimen such as tutorial-learning sessions, and remedial and formal educational classes. In the TCA planning confer- ence, increased attention to family, education, and vocational services was called for. Holland (1982) found reentry activities focusing on vocational skills, productive activities such as educational programs, interpersonal skills training, and family and other forms of counseling were important components of residential treatment. In TOPS, information was obtained on seven different types of services dis- tinct from drug abuse counseling: medical, psychological, family, vocational, educational, legal, and financial. Clearly, in a residential facility it is difficult to separate specific services within the holistic approach to treat- ment. Despite this problem, residential clients did report receiving a vari- ety of services (see table 13). Medical and psychological services were reported by more clients than any other type of service. Roughly 12 to 39 percent reported receiving services for other problems. The relatively close agreement between the data sources is interesting. Well over half of the residents received services for two or three types of problems and another 20 percent received four to seven kinds of services. 46 Table 13 Clients Receiving Various Types of Services in Residential Programs Based on Client Self-Reports, Clinic Records, and Estimates by Program Directors (1979-1981) Type of Service Psycho- Educa- Medical logical Family Legal tion Job Financial 9 . 9 9 9 9 9 9 O 0 O 0 0 0 0 Clients' Self- Reports (n=422) 74.7% 53.1% 26.3% 18.9% 38.8% '12.3% 17.8% Clinic Records (n=422) 74.6 63.2 23.5 27.6 33.6 24.3 23.5 Estimates by Treat- ment Directors (n=11) 80.0 60.0 20.0 20.0 20.0 11.0 25.0 Medical Despite the low priority placed on physical health as a goal and the lack of discussion of medical services in the literature, services seem quite common in residential facilities. Clearly, clients may need medical services beyond the intake physical. Six of the 11 TOPS residences provided medical ser- vices in the program. All programs also referred clients to other health facilities. Six of these residences had formal written referral agreements. About three-fourths of the TOPS residential clients reported receiving medi- cal services during the first 3 months of treatment. The clinical/medical records and directors' estimates confirmed the client self—reports. Nearly half of the TOPS residential clients reported receiving a physical exam, 44 percent received some unspecified treatment from a doctor or nurse, 33 percent were referred to a hospital or clinic, and 14 percent received some other type of medical service. One-fourth of the clients said they received medical service less than once a month during their first 3 months in treatment, 38 percent received service 1-3 times per month, and 11 percent received service at least once a week during that period. At least half of the residents in any facility reported receiving medical services. In five facilities, over 90 percent of the clients reported services. In seven facilities, between 50 and 70 percent of the residents received medical services. Client self-reports indicated no change in the proportion of clients receiving medical services from 1979 to 1981. Clinic records, on the other hand, noted an increase from 70 percent in 1979 to 85 percent in 1981 (x2 = 10.7, p<.01). 47 Clearly, residential clients received extensive medical services beyond a basic physical exam. The paucity of information in the literature suggests that medical service is such a standard part of residential treatment that it does not warrant special mention. Given the rising costs of medical care and the fact that few residents report medical insurance coverage, this important component of residential treatment may require more attention. Psychological In the previous section on counseling, we discussed individual counseling and evidence of the use of psychotherapy as an addition to the group pro— cess in residential programs. Psychological services can be defined more broadly as "any mental healt.b or psychological services or help with emotion- al problems." All residences provided such services. All but two of the 11 facilities had referral arrangements; seven had formal written agreements. About half of the clients said they received psychological services in the first 3 months of treatment. Clinic records indicated about 60 percent had received such services. Again, there is a problem in differentiating psychological services from general drug abuse counseling. Group therapy or counseling was received by 43 percent of the clients, and individual therapy or counseling was re- ceived by 37 percent. Twelve percent reported receiving psychological tests, and 11 percent said they had received informal help from the staff for psychological problems. Roughly 20 percent were given psychological ser- vices once a week or less; 20 percent, 2-3 times per week; and another 20 percent received services approximately daily. There was wide variation among residences in both self-reports and clinical records. In one residence only 1 in 10 clients received psychological ser- vices. In four facilities, over 80 percent of the clients reported services. Clinical records of five facilities showed over 80 percent of their residents receiving psychological services. Clearly, a problem exists in identifying, labeling, and coding psychological services in residential programs. Regardless of the problem of definition, some type of mental health service did appear to be provided to a large proportion of residential clients. As with medical services, the clinic re- cords indicated the proportion of clients receiving psychological services has increased from 52 percent in 1979 to 77 percent in 1981 (x2 = 53.0, p<.001). The increase in psychological services was likely in response to the greater needs of the new, more troubled client populations entering residential treatment. All counselors and most of the directors say that current clients greatly need psychological services. Family The need for family services was expressed at the TCA planning conference (DeLeon and Beschner 1976). The separation of residents from their chil- dren and other family members makes effective intervention difficult. Some programs have been developed for mothers and children (Pearlman et a1. 1982). Stanton (1979) reported that the few studies of family therapy in therapeutic communities did not provide definitive results. He cited two major impediments to effective counseling: the TC's view of the family as a 48 destructive influence and the family therapist's view that the TC cannot involve the family. Despite these problems, Stanton believes family therapy should be a critical part of reentry. All TOPS residential programs reported providing some type of family therapy. Five facilities also provided services through referral. About one in four clients reported receipt of family services. These services were mainly in the context of individual counseling (20 percent) and group coun- seling (17 percent). Only 2 percent of clients reported any kind of child care. About 12 percent of clients received family services weekly or more often. In five facilities, less than 15 percent of the residents reported family services during the first 3 months of treatment. ® Despite renewed attention to the issue of family services, there still does not ‘ a“?! seem to be a strong orientation toward family services in most residential ‘ programs. This problem may become even more serious. In 1981 only 17 percent of clinic records indicated family services were provided compared to 30 percent in 1979 (x2 = 8.2, p<.05). This trend is similar but not as pronounced in client self-reports. Clearly some attention needs to be direct- ed toward the complex issue of providing effective family therapy for resi-- ential clients either in the program or as a part of aftercare. Vocational and Educational Vocational and educational services have long been advocated as important components of residential treatment (DeLeon and Beschner 1976; Wolkstein and Hastings-Black 1979). Not only are these components important in the reentry process (DeLeon and Rosenthal 1979; Holland 1982), but residential job functions are a central part of the residential experience (DeLeon and Rosenthal 1979). Vocational rehabilitation clearly has an important place in residential treat- ment. In a national study of 68 residential programs in 1977, Hubbard and Harwood (1981) found 66 offered some type of vocational service; about half had some type of skill training. Two-thirds of the facilities had full-time vocational staff. One problem noted by Brown (1979), Hubbard and Har- wood, and Wolkstein and Hastings-Black involved reentry and aftercare. In order to find jobs after treatment, programs need effective staff to locate jobs and help place clients. Brown questions whether ex-addict treatment staff have sufficient experience with outside jobs to help clients with the job search. All of the TOPS residential programs reported that educational services were available in the program. Six had informal referral agreements with educa- tional programs, and four had formal written agreements. Only 3 of the 11 residence directors said that clients were very much or somewhat in need of educational services. Vocational services were available in only 5 of the 11 reporting facilities. Informal referral agreements were made by six facilities and formal agree- ments with vocational agencies were made by three facilities. Two other facilities which had in-house services had no type of referral agreement. 49 Only 3 of the 11 TOPS residential facilities had full-time vocational staff. Two others had half-time personnel. These results are very different from the 1977 findings of Hubbard and Harwood. The availability of both services and staff appear to have declined dramatically. Even though the TOPS sample is not statistically representative, the level of vocational services in TOPS programs leads one to believe that such services have been drastically curtailed. Neither educational nor vocational services are as widely reported by clients as one might expect. Educational services during the first 3 months of treatment were reported by about one-third of the residents. Individual counseling on educational problems (7 percent), courses in the program (27 percent), and referral to educational programs were the most common types of educational services. Services were received weekly or more often by 12 percent of the clients. Clinic records showed a similar proportion. Vocational services were reported during the first 3 months by only about 1 in 10 residents. Over the course of treatment, the clinical/medical records showed that about a fourth of the residents received job or vocational ser- vices at some time. Vocational assessment (3 percent) and individual coun- seling (5 percent) were the only services mentioned to any extent. Only about 4 percent of the residents reported receiving vocational services more than once a week. Those in treatment longer were more likely to receive services. After 1 year in residential treatment, 35 percent had received services, including vocational assessment (9 percent), counseling (10 per- cent), and referral to departments of vocational rehabilitation (13 percent). Clinic records from five residences showed less than 10 percent of the clients received vocational services. Self-reports of educational services showed a marked drop from 48 percent in 1979 to 37 percent in 1981 (x2 = 13.4, p<.01). This was further evidence of a disturbing trend toward less rehabilitative services. Overall, however, clinical/medical records showed that job services were provided to 33 percent of clients in 1981 compared to 19 percent in 1979. Self-reports indicated little change in vocational services. Clearly, more attention needs to be given to the critical area of vocational services. The need for services did not diminish, but there is strong evidence that fewer programs delivered services, and fewer clients received them. Legal and Financial Services Little information is available in the literature on the two other types of services: legal and financial. In general, about one in five clients reported receiving these types of services, and clinic records showed about 25 per- cent of clients Were receiving help. Four facilities provided legal help, and eight financial help, mainly through referral to social service agencies. Records in five residences indicated at least one-third of clients get help with financial problems. In six clinics, according to clinic records, over 25 percent of clients received some kind of help with legal problems, mainly assistance in court appearances. Such problems can be important in the initial client adjustment. Problems outside the program may contribute to early dropout. Resolution of legal and financial problems early in treatment may increase retention rates. 50 Number of Service Areas In order to assess the scope of services offered to clients, we looked at the number of service areas each client reported and the number of areas record- ed in the client files. Most of the individual residences delivered a variety of services. No residence could be labelled as either a high or low provider of services. Clinic records also indicated that more clients in 1981 (90 percent) were receiving services in two or more areas than in 1979 (63 percent) (x2 = 24.5, p<.001). Client self-reports for the first 3 months in treatment showed no evidence of trends. Just over 90 percent of the clients said they had re- ceived at least one type of service in the first 3 months of treatment. The clinic records indicated that a third (37 percent) received four or more kinds of services, and 41 percent received at least two types of service over the course of treatment. SATISFACTION, SUCCESS, AND AFTERCARE Graduation is certainly the ultimate goal of the TC. However, as DeLeon and Rosenthal (1979) reported, only between 10 and 15 percent of those ad- mitted graduate from the program. Long-term outcome studies revealed posi- tive outcomes even for those clients who did not graduate (DeLeon 1984; Sells et a1. 1976). Factors contributing to this success may include the help clients received from the program for their drug abuse and other related problems and/or the aftercare services that were available to them (Brown 1979; Brown and Ashery 1979). In TOPS the rate of graduation appeared to be similar to that reported by DeLeon and Rosenthal. Because a number of clients were still in treatment at the time of the treatment process study, an accurate assessment was not possible. Among the clients who left after remaining in treatment at least 3 months, about 20 percent graduated, about 60 percent dropped out, and the rest were discharged for noncompliance or left for other reasons. In general, the clients' ratings of their treatment programs were quite favor- able. Only about 2 percent said they were not at all satisfied with their treatment, and 6 percent said their program had not helped them to reduce their drug use. The directors of all residences, with one exception, said they frequently or always provided aftercare. The typical period was for at least 6 months. There was not, however, substantive evidence that many clients received aftercare services. At the time the clinical files were' examined, 73 percent of the TOPS residential clients had left treatment. Of those, 10 percent had notations that indicated followup or aftercare services. The provision of aftercare varied greatly across the programs. In one facility, all clients received followup or aftercare services. In three others, 71, 19, and 30 percent received some type of aftercare. In half the pro- grams, 5 percent or fewer received followup care or aftercare. There was a trend toward fewer clients receiving followup or aftercare services (x2 = 6.0, 51 p<.05). Given the high probability of relapse for many clients, especially those who do not graduate from treatment, aftercare services appeared to be needed. More careful attention to the impact of aftercare services and how they might be provided is needed to convince programs of the effectiveness of aftercare services. Clients were also asked to rate the extent to which the program had helped them to reduce their use of illicit drugs. Over three—fourths said their treatment had helped "a lot." Clients were less favorable when appraising the helpfulness of the program with problems other than drug abuse. About half said their treatment had been "very helpful," 44 percent rated it as "somewhat helpful," and just under 6 percent said their treatment had not helped at all with problems other than drug abuse. This general level of satisfaction seems to indicate that programs are achieving their objectives, and clients are satisfied with the approaches. The levels of satisfaction were consistent across programs and did not change over the 3 years of TOPS. SUMMARY Over the past decade, major changes occurred in the nature of the client population and treatment in residential programs. Trends toward shorter tenure and integration of professional and ex-addict staff were observed. These changes were made to better serve a more diverse client population with more complex problems. The major characteristics of residences in TOPS were: 0 Free-standing publicly funded facilities. The cost per client in 1980 for TOPS programs was around $6,100. Even after accounting for inflation, this is somewhat under the $7,300 figure for 1982 NDATUS. Both figures are well under costs that would have been projected from 1976 figures. 0 Clients had a broad range of problems. Although over half the clients were opiate users, there was a trend toward more nonopiate users entering programs. Some residences seem to focus purposefully on either heroin addicts or nonopiate users. 0 Although the proportion of females in residences increased, four of five residents were males and many residences were predominantly male. Some clinics had a Hispanic population (10 percent or more). Younger clients (under 21) composed no more than 20 percent of the clientele in any of the resi- dences. 0 Legal referral appeared to be increasing, and involvement with the criminal justice system was common. Over half the clients had prior treatment. 0 Clients had a multiplicity of drug-related problems, primarily family (72 percent) and depression (60 percent). 52 Admission processes typically took 1 to 2 weeks. Clients did not seem to be aware of treatment plans. Most counseling was done in group sessions. Weekly individ- ual counseling in most facilities supplemented the group coun- seling. A variety of services, in addition to drug counseling, was reported, including medical services (75 percent), psycho- logical (53 percent), and educational (39 percent). Trends in self-reports indicated fewer clients were receiving family and educational services. Fewer vocational staff were avail- able in programs than were available in the mid-19705. Graduation rates were about 20 percent. Except for one program, few residents had a record of aftercare services. 53 4. OUTPATIENT DRUG FREE PROGRAMS Literature on the outpatient drug free modality (OPDF) is extremely sparse, perhaps because it subsumes such a wide variety of approaches to treatment. Indeed, individual programs within the modality may have nothing in common except that they emphasize counseling, do not depend on medication, and are not residential. Quinones et al. (1979) stated that OPDF programs began in response to a need for community-based treatment clinics to which addicts could turn in crisis situations. These "crisis clinics" then evolved into longer term coun- seling and treatment programs. These authors also described OPDF clinics as ”generally, but not always" staffed by ex—addicts from the community. Kleber and Slobetz (1979) pointed out that, as of 1979, OPDF was the most popular modality, accounting for about 58 percent of all clients then being treated. They also provided a brief overview of the main subtypes of treat- ment approaches within this modality. The programs vary widely, from drop—in "rap" centers to highly structured programs. Most provide a vari- ety of services with some form/ of counseling or psychotherapy as the back- bone of treatment. Services for physical and mental health, educational, vocational, legal, and other problems may be provided within the program or through referral to other social service agencies. Ten OPDF programs participated in TOPS. One of these had closed before the special data collection for the treatment process phase of TOPS. Thus, client interview data are available for all ten OPDF programs, while clinical/ medical record data and staff interviews are available for nine programs. In this chapter, these data—-as well as data from NDATUS and other sources-- are used to describe the TOPS OPDF programs and their philosophies and methods of treatment. SIZE AND STRUCTURE The typical OPDF program reporting to NDATUS in 1979 had about 40 clients enrolled. In contrast, the TOPS OPDF clinics were much larger, with an average of about 160 clients enrolled in treatment at any given time. Three of the nine clinics whose staff provided information had fewer than 100 clients; two clinics had 200 and 240 clients, respectively. The smallest 54 TOPS OPDF clinic had 80 clients in treatment-roughly twice the NDATUS average. The reason for this discrepancy is unclear, but if the NDATUS figures are correct, an average clinic would need only two full—time treat- ment staff, assuming every client came in once per week and the staff mem- ber spent 50 percent of his or her time in direct treatment on an individual basis. Even though the TOPS programs may have been larger than mdst, the NDATUS figures still appear low. Program settings vary. Of the approximately 2,000 OPDF programs which reported to NDATUS in 1979, about one-third were free standing and an- other third were affiliated with CMHCs. About 11 percent were hospital based, 4 percent were affiliated with correctional facilities, and 18 percent were in other settings or environments. TOPS programs had a similar distri- bution. Three TOPS clinics were affiliated with community mental health centers. Four other programs were free-standing, community-based pro- grams that had specialized treatment emphases (such as vocational rehabili- tation or emergency treatment) or served specific populations (such as criminal offenders or clients with sexual identity problems). Two programs were parts of larger or more comprehensive drug abuse treatment programs, and the remaining program was hospital based. Over 75 percent of TOPS OPDF clients said their programs were easy to get to. STAFF Given that OPDF programs emphasize counseling in place of medication, it was not surprising that the percentages of psychologists and social workers on OPDF staffs were higher than in other treatment modalities. According to 1979 NDATUS figures, psychologists and social workers made up one-fourth of the staff in OPDF programs compared to 8 percent in other types of programs. The 1982 NDATUS figures were virtually identical to the 1979 data (see table 14). The percentage of physicians, nurses, and other medical personnel was about 3 percent in OPDF programs compared to 33 per- cent in methadone programs. Counselors made up an average of 42 percent of the staff in the OPDF programs reporting to NDATUS. In the TOPS programs, the percentage of staff time consumed by medical personnel was 2 percent or less in five of the programs and 8 to 12 percent in three other programs. Data were not available for the two remaining TOPS OPDF programs. Psychologists, social workers, and other counselors (including vocational rehabilitation counselors) accounted for one-half to two-thirds of the total staff time in five clinics and 86 to 99 percent in the three other clinics for which data were available. The remaining staff hours were devoted to administration of the programs. It is evident, then, that the principal focus of treatment in these programs is on the social and psychological rehabilitation of the client. The characteristics of the treatment directors and counseling staff can great- ly influence the nature and quality of treatment and, therefore, treatment outcome. As the work of Rogers and Dymond (1954), Strupp (1973), and others demonstrates, identifying and quantifying the "active ingredients" of successful treatment are difficult. In TOPS we obtained data on several demographic and background characteristics of the treatment staff. The directors of the TOPS OPDF programs averaged 38 years of age; 6 of the 10 55 clinic directors were women and all but one were white. The directors averaged 6.5 years of experience in their current program and, on average, just over 7 years of experience in drug abuse treatment. Two directors had bachelor's degrees, six had master's degrees, and one had a Ph.D. The counselors who provided information had all been employed in their current programs for at least 1 year. They averaged nearly 5 years in their cur- rent programs and just over 6 years in drug abuse treatment. Of the 19 who responded, two had Ph.D.'s, nine had master's degrees, one had some graduate coursework, two had bachelor‘s degrees, and the other five had high school diplomas or some college level coursework. Thus, the treatment staff in the TOPS OPDF programs appeared to be well educated, highly experienced and relatively stable employees. They averaged just over 37 years of age; 11 were men and 15 were white. Three of the five minority counselors were employed in one program. TABLE 14 Percentage of Hours Worked by Different Types of Staff in NDATUS Outpatient Drug Free Programs in 1979 and 1982 Staff 1979 1982 Physicians 1.3% 1 .390 Psychologists 8.8 10.8 Nurses/Medical 2.0 1.5 Social Workers 16.3 13.9 Counselors 42. 3 42.5 Bachelors degree 25.3% N/A Associate degree 3.5 N/A Nondegreed 13.4 N/A Other Direct Services 4.0 3.2 Administrative/support 25.3 26.8 All Staff 100.090 100.0% n=4688 n=6269 Ex-addict counselors were not used to a great extent in TOPS OPDF pro— grams. Five of the nine directors and 11( of the 20 counselors said they were not used at all. All others except one counselor said they were used "to some extent." Clearly, the emphasis is on employing professionally trained treatment staff. These findings are in contrast to the description provided by Quinones et a1. (1979) in their paper on OPDF programs. APPROACHES AND GOALS The treatment directors were given brief descriptions taken from a typology developed by Sells and his associates (Cole and James 1975): 56 DRUG FREE - CHANGE—ORIENTED PROGRAMS Within the drug free modality the goal of the change-oriented program is complete resocialization of the addict in order to enable the client to live a drug free life in the community. The treatment strategy for the change-oriented programs generally focuses on the young person who is not a hard core addict. The typical change-oriented program is highly struc- tured and has phases of treatment with clearly defined rules of behavior that are enforced by heavy sanctions. The addict is expected to spend virtually all of his or her waking hours in the structured therapeutic environment. Reentry processes are usually built into the treatment. DRUG FREE - ADAPTIVE PROGRAMS The goal of the drug free-adaptive treatment type is to reduce the addict's need for drugs as a means for coping with societal pressures. Expecting the addict to return to a totally drug free life is not considered realistic. The typical treatment strategy of the adaptive programs is to turn no applicant away-unless medical problems demand refer- ral elsewhere. Counseling is available as needed, and virtu- ally no structure is injected into the therapeutic process. It is designed to meet the immediate needs of the addicts and in many ways may be thought of as extended crisis care. The initiation and termination of the interaction between the addict and the treatment staff are controlled by the addict and generally occur as a result of personal crisis situations. No provisions for termination are provided because of the view that the addict will always need some supportive therapy. Each director was asked to select the description which more accurately reflected the philosophy of his/her treatment program. Eight directors re- sponded to this question; five selected the adaptive type as most nearly descriptive of their program's philosophy and goals, and the other three directors selected the change-oriented type. Most of the directors said the major focus of their treatment intervention was the resocialization of the client. Again, this supports the OPDF programs' emphasis, already evident in the staffing patterns, that psychosocial rehabilitation of the client is the central theme of treatment. Further, the change-oriented programs may, with their focus on younger clients and their goal of a drug free life, be operating on a "secondary prevention" model. That is, they may stress early intervention and treatment of less established drug abuse patterns as a means of preventing greater difficulties as the clients grow older. In the DARP, roughly 30 percent of the clinics were of the change-oriented type as compared to about 38 percent of the TOPS clinics. Given the small number of OPDF clinics in TOPS and the fact that neither the DARP nOr the TOPS samples were statistically representative of OPDF programs as a whole, one cannot draw any conclusion from this difference. Researchers might be well advised to take these findings into account when planning studies of OPDF programs, as the program philosophy and goals may well be important determinants of treatment outcome. 57 CLIENT CHARACTERISTICS Overall, just over two-thirds of the OPDF clients were men and about 57 per- cent were 25 or younger. An average of 36 percent of the TOPS OPDF clients had not completed a high school education. Thirty—one percent had a high school diploma or its equivalent, and 33 percent had some education beyond high school. The overwhelming majority of OPDF clients were white. Nearly half of the clients had some legal system status at admission to treat— ment. Of those, 55 percent were on probation or parole, and 35 percent were on bail pending trial. Most OPDF clients were classified in the single nonopiate (25 percent) or alcohol and/or marijuana (36 percent) pattern groups (Bray et al. 1982). Almost none were users of heroin, and an average of only 11 percent were users of other opiates. In two clinics, however, 22 and 25 percent of the clients were users of opiates other than heroin. Roughly 19 and 22 percent began using their primary drug of abuse on a regular basis at age 16-17 and 18-20, reSpectively. Across all three cohorts, 36 percent of the clients were classified as heavy drinkers, suggesting that treatment for alcohol problems may be needed. Another 35 percent were classed as moderate drinkers. The number of prior drug treatment admissions was asked of the clients during the intake interviews and was abstracted from the clinic records. According to both data sources, roughly tw0-thirds of the TOPS OPDF clients had no previous drug abuse treatment, just under one-fourth had one or two previous treatment episodes, and about 10 percent had three or more prior admissions. Those previously treated had been in a variety of treat- ment modalities. Over half of the clients had no health insurance coverage. Data from the four OPDF clinics that remained in TOPS throughout the entire data collection period were analyzed separately to detect any possible trends. Very few trends were noted in the OPDF modality with regard to the charac- teristics of the programs or the clients. Aside from a slight trend toward self-referrals and away from legal system referrals (x2 = 61.4, p <.05) and a trend toward more private insurance coverage (x2 = 17.8, p (.01), no trends were observed in these data. Apparently the clientele of OPDF clinics had remained fairly stable, at least over the preceding few years. This clientele was young, relatively well educated, white, and primarily abusers of nonopiates, alcohol and/or mari- juana. Nearly half were legally involved, and the criminal justice system was the largest single source of referral. 'These characteristics may well have an impact on the types of problems these clients present as well as the type of treatme'iit that is planned for them. PROBLEMS PRESENTED AND ASSESSED While there is, apparently, no literature on the psychological or other prob- lems of clients entering OPDF treatment programs, the work of McLellan and his colleagues (1980) and the New Haven group (Rounsaville et al. 1982) has shown that clients in other modalities have a variety of concomitant problems 58 that could be addressed by treatment services. It is reasonable to believe that OPDF clients also have such problems. More than 80 percent of the clients reported having at least one type of drug-related problem. Family and psychological problems were the most fre- quently mentioned, but large percentages of clients said they had problems in each of the categories. In three of the clinics, more than two-thirds of the clients said they had psychological problems, while in three other clinics fewer than one-third said this. Similar results were found for other problem areas (table 15). TABLE 15 Problems Presented at Admission and During Treatment in Outpatient Drug Free Programs (n=373) Type of Problem Psycho- Educa- Medical logical Family Legal tion Job Financial 0 D O 0 O O O 1) 6 6 6 1: ’o 6 Client Self-Reports of Drug-Related Problems at Admission 37.7 47.7 54.0 41.6 33.4 39.3 Prese ting Com- plaint as Noted in Clinic Records 4.8 36.8 16.3 30.7 - 7.5 3.7 Problems uring Treatment as Noted in Clinic Records 12.5 53.0 36.1 18.9 14.0 18.3 5.7 Clients' Perceived Need for Services After 3 Months in Treatment 32.5 74.3 50.3 13.9 32.5 30.0 27.0 aComplaint/problem other than drug abuse. The clinical records were used to provide data on the clients' presenting complaints and other information pertinent to the clients' problems. The most frequently mentioned presenting complaint (70 percent) was drug abuse; however, 37 percent complained of psychological problems and over 30 per- cent said they had legal problems. As with the clients' reports of drug- related problems, the records in four clinics showed well over half of the clients presenting with a complaint of psychological problems; in four other clinics fewer than 15 percent listed such complaints. Also, in three clinics, 45 to 65 percent listed legal problems, whereas in five clinics fewer ghan 59 20 percent of the records showed legal problems as a presenting complaint. Th’ree questions in the TOPS interviews addressed depressive symptomatol- ogy. In the intake interview, clients were asked whether, during the year before admission to treatment, they had (1) felt so depressed they couldn't get out of bed, (2) thought of suicide, or (3) attempted suicide. Just over 60 percent of the clients responded affirmatively to at least one of these questions, and 13 percent said they had attempted suicide at least once during that period. These are relatively serious indicators of depression. Clearly, this level of depression should be taken into account in planning the intake and treatment regimens. An intake assessment was recorded in all but 2 percent of the clinical re- cords. Somewhat surprisingly, only about half the clients (51.4 percent) received a primary problem assessment of drug abuse. Psychological prob- lems were listed as the primary problem for 23 percent of the clients, and legal problems were the primary problem in 17 percent of the charts. After they had been in treatment for 3 months, clients were asked whether they thought they needed treatment for any of several types of problems. Nearly three out of four clients said they needed services for psychological problems", and half said they needed services for family problems. Clinical casenotes provided information about the clients' problems during treatment from the counselors’ point of view. Psychological problems were mentioned in the files of 53 percent of the clients. Family problems were also mention- ed in many cases. In analyzing the data from the four OPDF programs that remained in'the TOPS over the entire data collection period, there appeared to be a slight trend for clients to report fewer problems at intake; however, these results did not reach statistical significance. There was a significant trend for fewer clients to report drug-related medical problems (x2 = 6.7, p <.05) at intake. Also, fewer clients said they needed services for medical problems after 3 months in treatment (x2 = 13.9, p <.01). In all other respects, the cohorts remained stable over time. Clearly, the clients coming into treatment in TOPS OPDF programs had a variety of problems. They saw themselves as having problems and needing services; the program staff agreed, to a large extent, with that perception. It was also clear that the mix of client needs across clinics was greatly varied and, therefore, posed different staffing and program planning prob- lems in each clinic. Why clients with particular types of problems were disproportionately found in some clinics is unknown. TREATMENT PLAN AND PROCESS The data for this and the following sections describe clients who remained in treatment at least 3 months. In addition to information from interviews with clients after they had been in treatment for 3 months, data from the clinic records of the long-term clients were used in these analyses. Some informa— tion on services was also provided by the treatment directors. Whe'h asked if they had received a written treatment plan, 81 percent of the clients said they had not. However, 90 percent of the clinical records 60 contained formal, written treatment plans which had been signed by the clients. Some clinics appeared more able than others to make the plans salient to their clients. For example, in three clinics, 11 to 46 percent of the clients were unaware that formal treatment plans had been made for them. In the remaining seven clinics, 80 to 100 percent of the clients were unaware of these documents. Most of the treatment plans were intended to last 2 to 3 months. The treat- ment directors reported that the intended duration of the average client’s treatment was, on average, about 9 months. They also stated that the treatment plans were updated periodically. Six of the nine responding directors said the treatment plans were revised every 3 months, one director said they were updated every 6 weeks, and two other directors said revi- sions were made only as needed. According to the clinic records, however, roughly half of the treatment plans were never revised (26 percent) or were revised only once (25 percent). COUNSELING AsllebeumLSlobetz (1979) pointed out, counseling is the cornerstone of OPDF treatment. Brill (1981) described some of the treatment options avail- able to nonopiate abusers, such as crisis-intervention centers, counseling centers, and day centers. The counseling centers offer individual and group counseling as well as help with such problems as housing, employ- ment, welfare, and legal problems. In Safer and Sands' (1979) review of the Sandorf et a1. (1978) study of free-standing and CMHC-affiliated OPDF programs, it was found that most patients in these programs received indivi- dual counseling, and more than one—third were seen in group counseling. Family counseling was more often available in free-standing programs. It was also suggested that amphetamine abusers presented more problems in treatment and needed more services than abusers of other drugs. Although counseling is the central feature of OPDF treatment, its precise nature is extremely difficult to capture. Only an intensive long-term obser- vational study can gather information in sufficient detail to describe the full range of topics, emotions, and personal interactions that go on in the coun- seling sessions. Even casenotes may omit some of the influential features of the counseling relationship or activities. In this section we describe the counseling in TOPS OPDF programs to the extent possible within the limita- tions of reports of clients, counselors, and directors. Caseload Twenty OPDF counselors provided information for the TOPS treatment pro- cess study. Six of these counselors had from 2 to 11 clients each. Five other counselors had 15 to 20 clients, and the remaining nine counselors had 24 to 35 clients each. The directors of the TOPS OPDF programs said the average caseload in their programs was about 20 to 30 clients per counselor. The size of the particular program, i.e. , the total number of clients enrolled at any time, appears to be unrelated to the client/counselor ratio. 61 Type of Counseling Nearly 80 percent of the clients said their counseling was all or mostly all individual, although this percentage varied from 40 to 100 across clinics. When asked about the frequency of counseling sessions, 13 of the counselors said that group sessions were held once a week, one counselor said twice a week, and three said they never held group counseling sessions. Fifteen counselors scheduled individual sessions once a week, four counselors sched- uled them twice a week, and one counselor scheduled them less than once a week. Group counseling sessions lasted 90 minutes, according to nine counselors, while five others scheduled theirs to last 2 hours. One counselor held 1-hour group sessions. Three-fourths of the TOPS OPDF counselors held 1-hour individual counseling sessions; five counselors had individual sessions lasting 45 minutes. The clinic directors stated that both group and individual counseling ses- sions were held once per week. Six of the directors said group sessions lasted 90 minutes in their clinics, and two other directors said they lasted 2 hours. One director said individual sessions were 45 minutes long; eight directors said they lasted an hour. When asked about the type of counseling they preferred, most OPDF clients said that the counseling they were receiving (i.e., mostly or all individual) was "about right." Of those who wanted something different, nearly all said they wanted more individual counseling. About 1 client in 10 wanted more group counseling. Focus and Techniques The directors and counselors were asked to provide information on their approaches to treatment, that is, the particular focus or emphasis of their counseling. Six of the nine responding directors said that a major emphasis was placed on individual, supportive counseling in their clinics. Three directors placed a heavy emphasis on the traditional, analytic approach in individual psychotherapy. In two other clinics the major focus was on individual counseling using behavioral or behavior modification techniques. Three directors said that their programs placed a heavy emphasis on group counseling sessions using a problem-solving approach. Sensitivity groups were emphasized in two programs and one program focused on encounter groups. Regardless of the particular method, two-thirds of the directors said their principal goal was resocializing the client or changing the client's life style. One director said practical problem-solving for day-to-day living was the major goal of treatment. Three—fourths of the counselors who were surveyed said the major focus of their intervention was the resocialization of the client; four counselors said practical problem-solving was the focus of their counseling. When asked to rate the degree of emphasis they placed on each of several approaches to therapy, the counselors varied considerably, even within the same clinic. 62 The counselors were also asked to rank six common treatment goals in order of importance. As one would expect, the counselors varied in their rank- ings, although not to a great extent. The most important goal, based on the average of all the counselors, was self-confidence or self-esteem, followed closely by coping skills and becoming self-supporting. Self-awareness and self-insight came in third, with social goals such as ethics and communication skills in fourth place. Fifth and sixth ranks were assigned to abstinence from illicit drugs and physical health, respectively. Matching of Clients and Counselors Six of the nine directors said that little or no attempt was made to match the clients with specific counselors on the basis of their characteristics. The other three directors said that such attempts are made "to a great extent" in theirclinics. The counselors in those clinics agreed that there are system- atic efforts to match clients with specific counselors to a great or very great extent. In the remaining clinics, the counselors gave varying opinions. For example, in one clinic each of three counselors rated the matching efforts differently. On the whole, it appears that some attempt was made in most clinics, but that only in one or two of the programs did the matching effort receive much emphasis. Data from the clients' records indicated that two-thirds of the clients had one primary counselor; an additional 23 percent had two primary counselors during their course of treatment. Thus, it seems that there was sufficient opportunity for most clients and their counselors to develop a good rapport. Given the influence the counselor/client relationship may have on treatment outcome, both matching staff and client and developing rapport warrant further attention from researchers. SERVICES Although counseling or psychotherapy is the cornerstone of OPDF treatment, it is clear that the clients have problems aside from drug abuse that might benefit from treatment. The TOPS interviews gathered information on seven types of services apart from drug abuse counseling. The seven categories of service are medical, psychological (i.e., mental or emotional), family, legal, educational, employment, and financial. After they had been in treat- ment for 3 months, clients were asked about the number, types, and fre- quency of services they received. Similar information was obtained from the clinical/medical records maintained by the clinics. In addition, the clinic directors estimated the percentages of their clients who were receiving each type of service. Table 16 shows the seven categories of services and the-percentages of clients who received each type of service based on our three sources of information. More detailed discussions of these services are found in the sections that follow. 63 TABLE 16 Clients Receiving Various Types of Services in Outpatient Drug Free Programs Based on Client Self-Reports, Clinic Records and Estimates by Program Directors (1979-1981) Type of Service Psycho- Educa- Medical logical Family Legal tional Job Financial 90 9o % 9° % 90 90 Clients' Self- Reports (n=373) 27.8 71. 3 45.9 6.5 19.0 12.6 9.0 Clinic Records (n=373) 46.1 79.0 33.7 23.4 15.0 17.4 5.4 Estimates by Treatment Directors (n=9) 35.0 99.8 39.0 12.0 14.0 25.0 15.0 Medical Overall, about 28 percent of the TOPS OPDF clients reported receiving some sort of medical service during their first 3 months in treatment. In con- trast, the clinic records indicate that 46 percent received such services. Fifteen percent of the clients said they received a physical exam, 4 percent were referred to a hospital or clinic, and 8 percent reported receiving some unspecified care from a physician or a nurse. Less than 3 percent reported receiving any other type of medical service. Slight trends toward fewer OPDF clients receiving medical services were evident in both the client self-reports (x2 = 6.8, p <05) and the clinical records (x2 = 5.7, p <.06). Psychological Psychological services or help with mental health problems were received by more OPDF clients than any of the other service types. Indeed, nearly all of the directors estimated that 100 percent of their clients received some type of help for psychological problems. The clinical records indicated that 79 percent received these services, and 71 percent of the clients said they had received some type of psychological service or help with problems. Given the nature of OPDF treatment, with its heavy emphasis on counseling and psychotherapy, it is difficult to separate psychological services (i.e., services for mentalhemotional, or behavioral problems) from the counseling received for drug abuse problems. This orientation would also lead one to expect very large percentages of OPDF clients to receive psychological ser- Vices. 64 The clients reported receiving several different kinds of psychological ser- vices. Fifty-four percent said they received individual psychotherapy and 13 percent reported receiving group therapy. Small percentages also report— ed taking psychological tests (4 percent) and receiving informal help from the staff (2 percent). A trend toward more clients receiving psychological services was found in the client reports (x2 = 15.1, p <.01), but the re- cords indicated no differences over time. Family Eight of the nine responding directors said that services for family problems were provided directly in their clinics. Further, they said their clients were somewhat or very much in need of such services. On average, 46 per- cent of the clients reported receiving family services; however, the clinical records indicate 34 percent received services. Most of the clients who received family services received individual counseling; many also received group counseling. In View of the fact that an average of 60 percent of OPDF clients were living with their parents or a spouse, it seems likely that family services would be appropriate and beneficial to both the clients and the family members. With respect to family services, the client interview data showed no significant differences, but the clinic records revealed a trend toward fewer clients receiving this type of service (x2 = 9.1, p <.01). Vocational Four directors said that vocational services were provided directly in their clinics, and at least one other provided services through referral; however, relatively few clients (13 percent) reported receiving such services. The clinic records showed 17 percent as receiving vocational services. Specifi- cally, 9 percent of the clients said they received individual counseling for vocational or job-related problems, and the remaining 4 percent received group counseling, job training, job placement, or a referral to either CETA or the department of vocational rehabilitation. One of the TOPS OPDF programs specialized in vocational rehabilitation (VR) and training. Its staff included four full-time VR counselors; 75 percent of the clients in this program were unemployed. Aside from the specialized program, there only was one other TOPS OPDF program that employed a VB counselor (28 hours per week). The remaining eight programs had no personnel specifically for VR services according to the NDATUS staffing data. Overall, nearly 44 percent of OPDF clients were unemployed. Here again, it would seem appropriate to provide services related to skills train- ing, job placement, and vocational guidance, perhaps through referral ar- rangements with local VR agencies. Educational, Legal, and Financial Services Very few of the TOPS OPDF clinics provided educational, legal, or financial services in-house or through formal referral arrangements. Also, relatively few clients (6 to 19 percent) reported receiving these services. The clinic records, in general, agreed with the clients' reports. 65 Nearly 40 percent of OPDF clients were referred to treatment through the criminal justice system, but only 6.5 percent of the clients and 23 percent of the clinical records indicated receipt of legal services. Perhaps even the one-fourth of clients who did receive these services were not fully aware of the activities in their behalf or, perhaps more likely, they received legal services at other agencies and did not perceive them as being provided through the treatment program. These three types of services can play an important role in the overall treatment regimen for many clients. It may be that more OPDF clients received these services than were identified in the TOPS data because the primary counseling sessions covered a variety of problem areas. More detail- ed examination of the content of these counseling sessions is needed to fully understand the nature of OPDF treatment. Number of Service Types In addition to examining the particular kinds of services clients received, we also looked at the number of different types of services they received. During the 3-month intreatment interviews, over half the clients said they had received services for two or three different kinds of problems and another 10 percent said they had received services of 4 to 7 types. The clinic records revealed over 60 percent receiving 2 or 3 types of services with an additional 10 percent receiving 4 or more. Analysis of clients' self-reports of services revealed a trend toward receipt of more services (x2 = 10.9, p<.05). In contrast, a trend toward receipt of fewer services (x2 = 24.3, p<.001) was found in the clinical record data. These data are shown in table 17. TABLE 17 Trends in the Number of Services Received by Clients in Outpatient Drug Free Programs Cohort 1979 1980 1981 n=79 n=71 n=74 9.. 9. % Number of Services Received - Client Interviews None 27.7 20.6 4.4 1 19.3 25.5 14.2 2-3 44.5 46.1 67.3 4 or more 8.4 7.8 14.2 Number of Services Received - Clinic Records None 10.3 4.3 1.8 1 12.9 21.4 33.6 2-3 69.0 72.1 54.9 4 or more 7.8 12.1 9.7 66 TREATMENT CONTEXT In any treatment program, 'the services available and the relationships be- tween the clients and their counselors constitute only a part of the pro- gram's total influence. An atmosphere or milieu also is a vital part of the program's character. Though nebulous and difficult to measure, this context may help to set a tone or attitude that can help or hinder the program's effectiveness. The work of Moos (1974, 1975) and others (Bliss et a1. 1976; Murdock et al. 1980; Penk and Rabinowitz 1978-1979) has demonstrated the relationship of these contextual factors to treatment outcome in inpatient programs. Apparently no similar studies have been made in OPDF programs. Some data are available in TOPS which may reflect treatment context. They have to do with the level of client participation in the program and the clients' perceptions of program effectiveness on several dimensions. The directors were asked the extent to which program activities, as outlined in the treatment plans, were considered to be mandatory. Four of the nine responding directors said to a "great" or "very great" extent, four said "to some extent" and one responded "not at all." These responses indicate a wide range in attitudes across programs. The directors were also asked the extent to which they required their clients to conform to the program's rules and regulations. Again, the responses were quite varied. Overall, how- ever, the directors placed a heavy emphasis on conformity. The directors and counselors were asked what methods they used to encourage their clients to participate or to discourage undesirable behavior. Peer pressure and verbal reprimands were used to a greater extent than loss of privileges, but there was considerable variation from counselor to counselor. In contrast, counselors were nearly unanimous on the question of how well their clients kept their counseling appointments and participated in the scheduled program activities—-18 of the 20 counselors responded that their clients "frequently" kept their appointments. One counselor responded "rarely" and another responded "occasionally." Clearly, the majority of clients were participating in their treatment programs to an acceptable level. The clients were asked to rate their programs on three dimensions: (1) ac- cessibility, (2) staff qualifications, and (3) the strictness of program rules and regulations. In general, the clients gave good marks to their programs on all three counts. Roughly three-fourths of them said that their programs were easy to get to and that the staff was well trained and well qualified. Over 95 percent said the strictness of the rules and regulations was "about right." Clients were also asked to rate the treatment they received. Just over half the clients said they were "very satisfied" with their treatment. Very few clients said they were "not at all satisfied." The clients also rated the extent to which their treatment had helped them to reduce their use of illicit drugs. About half said the program had helped "a lot" and another 20 per- cent said it had helped "somewhat." Nearly 20 percent said the program had} not helped at all in reducing their drug use. Most of the clients were pleased with the programs' helpfulness with problems other than drug abuse. Overall, only 7 percent said their treatment had been of no help with these problems, 45 percent said it had been of some help, and the remaining 48 percent said it had been very helpful. 67 Finally, they were asked whether the type of counseling they received was about right or whether they would prefer more individual counseling, more group counseling, more of both, or less of both. Most clients (70 percent) thought their counseling was about right, while roughly 20 percent said they would prefer more individual counseling. There were no trends and little variation evident in these data. PROGRAM COMPLETION AND AFTERCARE It has been shown that time in treatment-~regardless of modality/environ- ment--is positively related to successful outcome (Bale et al. 1980; Cushman 1977; Dole and Nyswander 1976; Simpson 1981; Sugarman 1973; Szapocznik and Ladner 1977). Therefore, this variable may be used as an indicator of the success of a treatment program. Also, the clients' reasons for leaving treatment may reflect program efficacy. Overall, more than one out of five TOPS OPDF clients left treatment in 1 week or less after admission. Another 15 percent left after 2-4 weeks, and another 15 percent after 5-8 weeks. Thus, well over three out of every five clients left treatment in less than 3 months. About 20 percent stayed in treatment 3 to 6 months, and nearly 17 percent stayed more than 6 months. At the time the clinic records were examined, three-fourths of the TOPS OPDF clients had left treatment. Over 40 percent of these had "graduated" or completed the treatment program, although this varied from 10 percent in one clinic to 67 percent in another clinic. Just over 35 percent had dropped out or left without completing the program. Again, this varied from a low of 7 percent to a high of 70 percent. On average, only 8 percent of the clients had been involuntarily discharged. In three clinics no one had left involuntarily, but in three others 14, 30, and 47 percent had been involun- tarily discharged. In analyses of the TOPS followup data, careful attention is being paid to possible differences in outcomes among those who graduated and those who did not. Clinics varied considerably with respect to the provision of followup or aftercare services. Of the eight directors who responded to this question, one said they always provided followup or aftercare services, two said they frequently did, four said they occasionally provided these services, and one said they did so only rarely. The posttreatment period during which these services were provided ranged from 3 to 12 months and averaged just over 8 months. There was, however, a trend toward fewer clients receiving follow- up or aftercare services (x2 = 10.7, p <.01). Analyses of TOPS posttreatment data are examining these services from the clients' point of view and attempting to determine whether those who receive followup or aftercare services perform differently on outcome measures such as employment, illegal involvement, drug use, and depression from those who do not receive them. Given the chronic nature of drug abuse and the high recidivism among drug abuse treatment clients, it seems that aftercare ser- vices would be an appropriate--perhaps even vital--part of a treatment regimen. The variance evidence among the TOPS OPDF programs provides an opportunity to test this hypothesis. 68 SUMMARY The 10 TOPS outpatient drug free programs were diverse, mostly free— standing facilities that were much larger than the typical NDATUS clinic. This may indicate that a large proportion of outpatient drug free clinics are parts of multimodality treatment systems. After achieving abstinence in a methadone program, for example, a client may transfer to an OPDF program in the same treatment system. Clientele included high proportions of whites, youths, nonopiate drug users, and individuals with many problems in addi- tion to drug use. Professional mental health training was a common staff characteristic in this modality. Very few trends were found. The major findings for TOPS OPDF programs include: 0 There were three types of units (CMHC affiliated, special treatment emphasis, or part of a comprehensive program) with an average of 160 clients. The average annual cost per client gas $2,000, 25 percent higher than the NDATUS cost of 1,600. 0 Staff had good educational backgrounds. Ex-addicts were not extensively used in counseling. 0 The two major therapeutic orientations of programs were resocialization and the teaching of coping skills. 0 About one-third of clients were female and 60 percent were under 25 years old. Half of the clients had some type of legal system status at admission, and two-thirds had no prior treatment history. Very few clients were heroin users. About one-third used no drugs other than marijuana and/or alcohol weekly or more often. 0 Diagnoses focused on problems other than drug abuse. Only half of the clients had a primary diagnosis of drug abuse. Clients mentioned a variety of drug-related problems, and about three-fourths stated a need for psychological services. Reports of depression were common (60 percent). 0 Treatment plans were emphasized in three programs, but in the other seven, few clients were aware of plans. The typical planned duration of treatment was about 9 months. 0 Individual counseling was the focus of treatment in OPDF programs. Counselor caseloads were typically between 20 and 30 clients. Individual sessions of about 1 hour‘were held weekly. Various approaches were used even within a single clinic. Despite varying therapeutic orientations of counselors, there appeared to be little attempt to match counselors and clients. 0 Psychological (71 percent) and family services (46 percent) were the services most commonly reported by clients. 69 The contexts for the OPDF clinics seemed to be diverse, especially in the requirement that clients participate in pro- gram activities. About half the clients felt the program had helped them reduce their drug use "a lot. " About 2 of 5 clients who remained in the program at least 3 months were noted as completing treatment. Aftercare ser- vices were not commonly reported, and the percentage with notation declined from 1979 to 1981. 70 5. SUMMARY AND IMPLICATIONS Program administrators, researchers, and policymakers generally agree that community-based methadone, residential, and outpatient drug free drug abuse treatment "has been instrumental in the rehabilitation of significant numbers of drug dependent individuals" (National Institute on Drug Abuse 1981, pp. 13-14) and has been associated with favorable outcomes, especially for clients who remained in treatment at least 3 months (Simpson and Sells 1982). There is no question that treatment works. The important questions are now: Why does treatment work, for whom does it work, and how can treatment be made to work most effectively and efficiently? Unfortunately, little information is available on treatment process in drug treatment programs (Allison and Hubbard, in press). Furthermore, much of the available data describe treatment in the early 19705. A recent survey of treatment program administrators and state agency directors (Greenberg and Brown 1984) indicated there may have been major changes in the nature of clients and treatment over the past decade, limiting the utility of much of the existing literature. More current information is clearly needed by treat- ment planners, program administrators, and researchers. The treatment process study conducted as part of the Treatment Outcome Prospective Study (TOPS) and funded by the National Institute on Drug Abuse provides the most recent data for a national sample of programs. ' STUDY DESIGN TOPS is a long-term, large-scale, longitudinal investigation of the natural history of drug abusers before, during, and after receiving services in publicly funded drug abuse treatment programs in 1979—1981. Although the major focus of the study is client outcomes, a principal goal of the TOPS research is the investigation of treatment received by clients. Extensive information on a variety of characteristics of treatment in outpatient metha- done, residential, and outpatient drug free programs was obtained from NDATUS, and in client interviews, queries of clinic staff, and clinic record rev1ews. Sample The sample for the treatment process study included 41 clinics (17 metha- done, 14 residential, and 10 OPDF) where samples of clinical/medical records 71 were available. In each clinic we attempted to obtain information from the director and supervisor or head counselor, as well as other counselors who had at least 1 year's experience in the clinic. Questionnaires were obtained from 37 of the 41 clinics. The other four clinics participated in TOPS only in 1979. Data for directors and counselors in 37 clinics and client interviews and clinical/medical records from 41 clinics were used in this study. Budget and staffing data from the NDATUS for 1980 were available for 36 of the 41 clinics. Samples totaling 1,351 clients retained in treatment a minimum of 3 months were drawn from the TOPS admission cohorts of 1979, 1980, ahd 1981. Instruments Client data were taken from the TOPS intake and 3-month intreatment inter- views. In addition, two data collection instruments were specially designed. The Clinical/Medical Record Review Form was designed to gather information from client files on a variety of topics relevant to treatment process, includ- ing services received, treatment plans, medications prescribed, and followup services. The Director Checklist, filled out by the treatment director at each clinic included in the TOPS treatment process study, covered program policy and philosophy, approach to treatment, emphases and goals for treat- ment, size of the program, caseload per counselor, services provided at the program or through referral, criteria for completion of program or for dis- charge from program, and many other variables relevant to the study of treatment process. Counselors completed a similar Counselor Checklist asking about their perceptions on these topics. OBJECTIVES OF THE TREATMENT PROCESS STUDY This report uses the available information about drug abuse treatment in the TOPS programs to answer five major questions: 0 What is the nature of treatment available and rendered in a large national set of selected methadone, residential, and outpatient drug free programs? 0 How useful is this information to treatment programs? 0 How has drug treatment changed over the past decade? 0 What changes might occur in the future? 0 What are the implications of the findings? The principal purpose of this report has been to provide a comprehensive and detailed portrait of major elements of drug abuse treatment, including descriptions of the programs, their staffs, and their clients. We have described these elements in the three modalities/environments that account for the vast majority of clients in publicly funded drug abuse treatment programs. Thus, this report serves as a basic framework for the understanding of treatment process. The next step will be the organization of these major elements into useful theoretical and research frameworks for studying the 72 impact of treatment and treatment components on various types of clients. These frameworks should also suggest ways in which the information can be used to improve the design and organization of treatment approaches. The following sections describe the major elements of treatment and the implica- tions of the findings for researchers and treatment programs. SIZE AND STRUCTURE In general, the clinics selected for TOPS were larger and more urban than the treatment programs reporting to NDATUS. Despite these differences, the findings should be applicable for most programs. All TOPS programs received most of their funding from public sources, often a variety of local, State, and federal agencies. The average TOPS methadone clinic had a capacity of about 260 clients with a budget per slot of about $2,000. Six clinics were community based, nine were associated with hospitals, and two were part of a comprehensive multimodality community health system. OPDF clinics averaged 150 clients and operated on budgets of about $2,000 per client slot. One-third were affiliated with community mental health centers. All 14 residential programs were independent and free standing, with an average of 64 beds and an annual expenditure of $6,135 per slot. TOPS residential and methadone programs typically had lower per client costs than the programs in NDATUS, probably because fixed administrative costs in the larger clinics were averaged over more clients. Per client costs for TOPS OPDF clinics were much higher than the NDATUS average of $1,575. This may be attributable to the professional level of staff in the TOPS pro— grams and the fact that all TOPS programs are free-standing facilities with separate administrative staffs. It should also be noted that the average per client budget in real dollars, adjusting for inflation, for NDATUS programs declined dramatically between 1975 and 1982 for outpatient drug free (-$234) and residential (-$667) programs. Budgets for methadone programs remained about the same. STAFFING Greenberg and Brown (1984) reported a decrease in the number of ex-addict counselors over the past decade. Staff in TOPS drug treatment programs appeared to have more formal education and training than treatment staff in the early 19705. There was less emphasis on the use of ex-addicts in coun- seling, particularly in methadone and outpatient drug free programs. In TOPS outpatient drug free clinics, staff had considerable formal training-- generally a master's degree. Ex-addicts were used only to some extent, if at all, in counseling. Most residential facilities had at least some degreed staff. Professional and paraprofessional staff apparently had been success- fully integrated in residential treatment. APPROACHES AND GOALS A majority of program directors and counselors saw a drug free life and reentry into the community as achievable treatment goals. 73 An impressive majority (but not all) of the directors described abstinence from drug use and complete reintegration into mainstream society as achiev- able goals of treatment. Less than one-fourth of the directors (mostly from OPDF programs) said that such goals were unrealistic. While TOPS residential programs had similar philosophies on resocialization and reentry into to the community, methadone and OPDF programs had diverse approaches to treatment. Varying opinions about maintenance and abstinence and treatment goals were found, even within the same methadone clinic. The two common orientations to treatment in OPDF programs were resocialization (changing the person's belief, values, and behavior patterns) and teaching coping skills (adapting to society). Our descriptive analyses have not revealed any clear, strong relationship between program philosophy and the intended duration of treatment, the treatment services provided, the criteria for completion of treatment, reten- tion in treatment, or any of several other measures. Such relationships are probably complex and will need to be analyzed using more sophisticated techniques. The lack of clear statements of treatment goals by staff could adversely affect clients' motivation and expectation about treatment and their success during and after treatment. Directors of two-thirds of the TOPS methadone clinics expected clients to remain in treatment 18 months or more. Residential programs typically re- ported a planned duration of 12-18 months, much shorter than the minimum 2-year graduation requirements of TCs in the late 19605. OPDF programs expected clients to remain in treatment about 6 months. The issues concern- ing duration of treatment are even more important in light of the fiscal restraints placed on programs in the last several years. CLIENT CHARACTERISTICS Other TOPS reports emphasized the differences in the client populations entering the three modalities. This report confirms that these differences are also found for clients remaining in treatment 3 months or longer. These differences clearly have important implications for the nature and extent of services delivered in each modality. 0 Clinics within modalities varied greatly in the nature of their client populations. Finding variation across modalities was not surprising. However, we also found extensive variation across clinics--even those which were units of the same treatment program. Thus, a large treatment program which operates several individual clinics is apparently just as likely to show interclinic variation as any set of unrelated clinics. 0 Demographic characteristics of clients differed among modali- ties but did not appear to change over the 3 years of TOPS. . The sex and age distributions of clients differed somewhat across modalities. We found no evidence that clients are becoming older or are more likely to be female. Methadone programs had higher percentages of women (35 per- cent compared to 20 percent in residential and 30 percent in OPDF) and clients over 30 years old (40 percent compared to 28 percent in residential and 23 percent in OPDF) than programs of the other two modalities. The OPDF clients were more likely to be under 21 (27 percent) than those in the other modalities (17 percent in residential and 2 percent in methadone). The modalities were quite different with respect to client racial or ethnic backgrounds. Methadone programs had the lowest percentage of white clients (45 percent as compared to 52 percent in residential programs and 88 percent in OPDF programs) and the highest percentage of Hispanic clients (18 percent as compared to 7 and 4 percent in residential and OPDF pr’o- grams). 0 Many clients in residential and OPDF programs were involved with the legal system. Referrals from the legal system were relatively rare among methadone clients but accounted for roughly 40 percent of referrals to residential and OPDF treatment programs. Methadone clients were most often self-referred (49 per- cent compared to 21 percent for residential and 20 percent for OPDF). Large percentages of residential (64 percent) and OPDF (48 percent) clients had some sort of legal system status, whereas most methadone clients did not. 0 Most clients had prior treatment experience. Roughly one-fourth of methadone clients, just over 40 percent of residential clients, and about two—thirds of OPDF clients had had no prior treatment for drug abuse. On the other hand, about 45 percent of methadone clients, 25 percent of residential clients, and 10 percent of OPDF clients had had three or more previous treatment episodes. 0 Multiple drug use was common among clients entering all modalities. Over 80 percent of TOPS methadone clients used opioids at least weekly in the year prior to treatment. Those who did not use opioids in the year prior to treatment were individuals who had used opioids daily at some time and, usually, who had transferred from other programs. Among residential clients, about 55 percent abused opioids. Roughly 25 percent of the resi- dential clients were classified as abusers of nonopiates other than marijuana, and another 12 percent fell into the alcohol and/or marijuana only groups. Most OPDF clients were classified in the nonopiate (25 percent) or alcohol and/or marijuana (36 percent) groups; 10 percent used heroin weekly or opiates other than heroin weekly. ' The TOPS results confirm the impression of State agency directors and program administrators (Greenberg and Brown 1984) that drug use patterns have changed over the past decade. Clearly, the different types of drug use patterns seen in the modalities and their associated problems suggest that need for special types of services in each of the modalities. In fact, the descriptive data demonstrate that there are indeed substantial differences in the nature and extent of services among the modalities. The key task for 75 evaluators and administrators is to determine whether the mix of services in a particular program effectively meets the needs of the types of drug abusers seeking treatment there. 0 Clients entering TOPS programs had a variety of problems in addition to and related to drug abuse. Large numbers of TOPS clients in all modalities reported drug-related medi- cal, psychological, family, and vocational problems. Again, the impressions of program administrators that clients have substantial social and personal problems were confirmed. Although most TOPS programs noted drug abuse as the principal problem, many identified other problem areas. The intake assessment may reflect the programs' view of drug abuse as a disorder or as a symptom. Clients in methadone programs were nearly always assessed as having a drug problem. Although in residential programs, the vast majority were evaluated as having primarily a drug problem, some clients were seen as having psychological problems. In outpatient drug free programs only about half of the clients received an intake assessment of a drug problem, while nearly one-fourth of the clients were seen as having a psychological problem. As will be discussed later, this initial diagnosis may lead to a very different mix of services for the client. The array of drug-related problems reported by clients varied markedly by modality. In methadone clinics, clients presented a variety of problems, often drug-related family problems (51 percent) and depression (52 percent). Different methadone clinics saw clients with different arrays of problems. Drug-related medical problems appeared to be increasing while family prob- lems were decreasing. Residential clients reported a multiplicity of drug- related problems, primarily family (72 percent) and depression (60 percent). Clients entering OPDF programs mentioned a variety of drug-related prob- lems. About three-fourths stated a need~for psychological services, and two of five clients reported depression symptoms. 0 Suicidal thoughts and attempts during the year prior to admission were critical problems for clients. Suicidal behavior was a major problem for clients coming into residential and outpatient drug free programs; 40 to 45 percent of these clients reported having thought of or attempted suicide during the year before admission compared to 26 percent of methadone clients. The TOPS results confirmed that clients entering treatment in 1979-1981 were more likely than in the past to have psychological problems, especially de- pression. These results demonstrate the need for a comprehensive assess- ment of client history and functioning at intake. TREATMENT PLANS Our finding that clients had little knowledge of their treatment plans was somewhat unexpected. Without exception, the treatment directors stated that formal, individualized, written treatment plans were prepared for their clients. Examination. of the clinic records revealed that nearly all of the 76 clients' files, indeed, contained such plans and that the plans had been signed by the clients. In the TOPS intreatment interviews, however, few clients reported having received a written treatment plan. Either of two explanations seems likely: The clients may have read and signed the treatment plan along with other documents and failed to remember it, or they may have dealt with the plan individually but failed to under- stand its name and purpose as described in the interview. In any case, it is quite clear that the clients, with few exceptions, appeared to be unaware or uncertain that treatment plans had been prepared for them. If, in fact, they were unaware of existence of the plan, one must also assume that they were equally unaware of its contents. An important question, therefore, is how well clients understand the nature, intent, and goals of their treatment. COUNSELING Individual counseling commonly was received and preferred by clients. Methadone and outpatient drug free clinics relied mainly on individual coun- seling or therapy, whereas residential programs used group counseling for most of their clients. When the clients were asked what sort of counseling they preferred, most (31 percent methadone, 19 percent OPDF, and 55 percent residential) said they would like to have more individual counseling. Counselor caseloads were 20 to 35 in most methadone clinics. In clinics with more long-term maintenance clients, the caseloads were higher. Individual counseling was the norm. Individual psychotherapy was reported by direc— tors and counselors to be used to some extent in 70 percent of the TOPS methadone clinics. Group sessions were the chief counseling mechanism in residential facilities. Weekly individual counseling in most facilities supplemented the group coun- seling. In OPDF programs, counselor caseloads were typically between 20 and 30 clients. Individual sessions of about 1 hour were held weekly. Various counseling and therapeutic approaches were used even within a single clinic. METHADONE IN TREATMENT A critical part of methadone treatment is the determination of the optimal dosage level. Clearly a full analysis of this complex issue is beyond the scope of this report. Low dose levels after 3 months in treatment (usually 20-70 mg/day) were common in most methadone programs. This is consistent with the findings summarized by Cooper et al. (1983). A trend toward lower dosage level was found. Take-home privileges were common, but clinics differed widely in the proportion of clients having take- home privileges. 77 SERVICES The TOPS data confirm that a variety of services were provided at the program and through referral (see table 18). Unfortunately, clients also appeared to have a greater need for services than in preceding years. Table 18 Client Self-Reports of Various Types of Service Received During the First 3 Months in Treatment Modality Outpatient Outpatient Type of Methadone Residential Drug Free Service (n=566) (n=422) (n=373) % 9° 90 Medical 35.3 74. 7 27 .8 Psychological 16.1 53.1 71.3 Family 10.2 26.3 45.9 Legal 3.6 18 .9 6 . 5 Education 5.9 38.8 19 .0 Employment 8.5 12. 3 12.6 Financial 4.9 17.8 9.0 The service most commonly reported by methadone clients was medical (35 percent), often including intake physicals. Psychological (71 percent) and family services (46 percent) were the services most commonly reported by OPDF clients. In residential programs, a variety of services in addition to drug counseling were reported, including medical (75 percent), psychological (53 percent), and educational (39 percent). Trends in self-reports over the years 1979-1981 indicated fewer residential clients were receiving family and educational services. Fewer vocational staff were available in residential programs in 1980 than in the mid-19705. Except for medical services, less than 10 percent of the methadone clients reported receiving each of six services distinct from drug counseling. Those results suggest that methadone program administrators should evaluate the need for more family, vocational, and psychological services. Even the clients who received services seldom reported receiving a service weekly or more often. As is the case for intake physicals in methadone programs, many of the services may be only for specific problems that occur only once during treatment. The essence of the treatment process as we found it in the TOPS treatment programs seems to be some sort of counseling or therapy, usually individual, and usually emphasizing the resocialization of the client, in combination with an array of ancillary services for problems other than drug abuse. Such characteristics as clinic size, counselor/client ratio, and program philosophy 78 varied considerably from one clinic to another (both within and across modali- ties), but most programs provided a variety of services to many of their clients. SERVICE NEEDS AND SATISFACTION The clients, in turn, seemed to want more of everything—~more counseling, more services for more different kinds of problems, and more individualiza- tion. Although clients in the TOPS programs did receive a variety of ser- vices, they also reported many "unmet" needs. Perhaps the most important finding of the TOPS treatment process study concerns the differences be- tween clients’ perceived need for various sorts of services for problems other than drug abuse, the treatment staffs' views of the clients' problems, and the services actually received by clients. In virtually all clinics in all three modalities, we found substantially higher percentages of clients who thought they needed services of various types than had received them. Also, the counselors' casenotes indicated that at least some of these "unmet needs" were recognized by the program staffs. The largest percentage of clients mentioned they needed psychological and family services. However, other needed services including medical, educational, legal, and employment were also mentioned by substantial proportions of clients in many clinics. Most clients in methadone and residential programs reported that they were satisfied or very satisfied with their treatment and that it had been helpful or very helpful in decreasing their illicit use of drugs. About half the OPDF clients felt the program had helped them reduce their drug use ”a lot." . The clients, although satisfied, were less enthusiastic in their ratings of the programs' helpfulness for problems other than drug abuse. It seems likely that this lower rating may be closely related to clients" perceived need for services and desire for more counseling or therapy. AFTERCARE Few clients received aftercare services. Although methadone programs reported the availability of aftercare services, only about one-third of the clinic records for terminated clients indicated any aftercare was provided. Except for one program, few former residents of therapeutic communities had a record of aftercare services. Aftercare services were not commonly re- ported in OPDF program records, and the percentage declined from 26 per- cent in 1979 to 5 percent in 1981. Most of the TOPS treatment directors stated that they regard reintegration with society at large as an important and achievable goal of treatment. Aftercare seems essential to the accomplishment of this goal. These results suggest, however, that few programs are successfully focusing on the key transition between program completion and reentry into the community. CLINICAL IMPLICATIONS The TOPS treatment process study was designed to identify some of the major components of the treatment process. While not intended to assess clinical practices in detail, the results do suggest some general guidelines 79 for more effective service delivery. Furthermore, the TOPS data indicate trends in client characteristics and service delivery that should be consider- ed in the continuing development of drug abuse treatment. These guidelines and considerations are highlighted below. The TOPS data confirm the impression that drug use patterns and problems of clients coming into treatment have changed drastically over the past decade. 0 Comprehensively assess and categorize patterns of drug abuse and alcohol abuse. Programs need to move beyond the traditional primary drug of abuse diag- nosis. Using only this simple measure obscures the extensive nature of multiple abuse and may lead to similar treatments for clients with very differ- ent abuse patterns. Alcohol abuse must also be assessed and considered in developing a treatment plan. 0 Assess the nature and extent of problems across all major areas of functioning. The large discrepancies between perceived needs of TOPS clients and ser- vices received suggest that staff should question their clients more thorough- ly about drug-related problems and other problems in living. The fact that drug treatment clients often experience a variety of problems with health, family, jobs, personal relationships, the law, and so forth is well documented and was borne out by the large percentages of TOPS clients in all modalities who expressed a need for services in these areas. Whether drug abuse is a cause or an effect of these concomitant problems, there is clear indication that the problems must be taken into account when planning the course of treatment. It is also recognized that the treatment programs have limited resources with which to meet this need and demand for services. G 0 Provide a diversity of services to clients through referral and interagency cooperation. One way many TOPS programs increased the diversity of services was through referral arrangements and interagency cooperation. Few clients, however, reported referrals. Another way to provide services may be to affiliate treatment programs of various types with larger, multifaceted pro- grams which address not only drug abuse but physical and mental health, financial, educational, and employment problems as well. 0 Develop clear treatment plans and counsel clients on these treatment plans. An important finding of the TOPS research was the clients' limited informa- tion on their treatment plans. Because clients are unaware of the treatment plans that have been prepared for them, it seems advisable for the treatment staff to make those plans more salient for the clients. It follows that the clients may also be unaware of or have only vague notions of the activities, goals, expectations, purposes, and other aspects of treatment. These goals should be stated in terms of behavioral objectives for clients and the optimal length of stay in program. To the extent that success is dependent on 80 motivation or is a self-fulfilling prophecy, the clients’ knowledge of and agreement with the contents of the treatment plan are important. The treat- ment plan may be a useful tool rather than a seemingly onerous and useless paperwork requirement. 0 Emphasize reintegration into the community as a treatment goal and advocate effective aftercare services. Aftercare seems essential to the long—term accomplishment of the goal of reintegration with society at large. The process might begin during treat- ment by placing drug treatment clients in such programs as vocational train- ing with people not in drug treatment. Aside from socialization and vocation- al benefits to the clients, cost sharing may be possible in such cooperative arrangements. These and other possible solutions to the problems faced by program planners and policymakers in economically providing comprehensive treatment should be explored and tested. After treatment, the client must have a mechanism for followup with the program and help in accessing com- munity services if needed. 0 Analyze budgets in detail, identifying fixed administrative and facility costs and variable counseling and service expenditures per client. The accounting and economic aspects of treatment management must receive more attention, given the decline in funding for programs and the increasing accountability requirements of public and private insurers. Cost accounting and cost-benefit analysis are essential to maintaining funding levels and using available funds effectively. Such analyses can help determine whether budget savings can be attributed to more efficient operations or decreased client services. RESEARCH IMPLICATIONS In the preceding sections we presented a number of results of the study of treatment process. Each result and recommendation was treated somewhat independently. No attempt was made to correlate the various elements of treatment or link them to outcomes. Both are formidable tasks that will require a substantial research effort. The relatively good agreement among the three data sources suggests that we have fairly solid information with which to study treatment services and other aspects of treatment process. Guided by the literature review and the results of this descriptive analysis, we hope to assess the effects of differ- ent types of treatment and, through the use of multivariate techniques, enhance our understanding of the effects of elements of drug abuse treat- ment on outcomes. The results of multivariate analyses including treatment process measures will be included in forthcoming TOPS reports on different types of behavior and outcomes for subgroups of clients. We propose four types of studies: 0 Identify the impact of particular elements of treatment on out- comes. 81 This approach is an essential first step in assessing impacts of treatment. Bivariate relationships should be confirmed within a multivariate model. The impact of specific types of services such as mental health and related behav- iors such as depression could be examined. The impact of intensity and integrity dimensions of treatment such as duration, quantity, and quality can also be assessed within this approach. 0 Develop and assess models of treatment and determine their effects. The finding of extensive variation among clinics--even among clinics belong- ing administratively to one program-carries important implications for re- searchers. Studies of single programs or elements of treatment can only be regarded as idiosyncratic, and generalization of results is likely to be mis- leading. Analyses of treatment data may have to be performed at the level of the individual client and the pattern of services received by that client with clinic, program, and modality level analyses having very limited use. Typologies of treatment that go beyond the gross classifications now available may not be feasible. It may be necessary to develop indices of patterns of service mix to fully describe treatment rendered. Clustering techniques as well as theoretically developed configural scoring could be used to identify service mixes. 0 Determine the effects of matching subgroups of clients with particular patterns of treatment. Once some basic models of treatment are developed, it may be possible to identify which elements or patterns of treatment are effective for particular subgroups of clients. Clients with multiple problems may be more refractory so that, even with the provision of more services, these clients may not respond to treatment as well as clients with fewer problems. This notion of treatability and the match of client needs and services will have to be taken into account in multivariate analyses and in attempts to model treatment process and outcome. 0 Conduct cost-benefit and cost-effectiveness studies of treat- ment. If components or elements of treatment can be identified, the costs of each element should be determined. Previous research on costs of treatment has generally (looked at aggregate cost figures rather than costs by component. The further specification of elements of treatment will allow us to better determine how much treatment is being rendered for the cost. Outcome analyses would identify the elements which produce the most improvement. The final outcome would be an assessment of how available dollars might be best spent to provide the most effective services. 82 REFERENCES ‘/Allison, M. , and Hubbard, R.L. Drug abuse treatment process: A review of the literature. Int J Addict, in press. 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