Community-based Residential Treatment Research Articles

Developing a realist theory of community-based residential substance use treatment

Community-based residential treatments for substance use disorders (SUDs) have mixed effectiveness, which has been hypothesized to be due to the variability of program offerings across treatments. Therefore, the purpose of the present study was to develop a realist program theory of a community-based residential treatment centre to understand which components of treatment are most effective, who benefits from treatment, and why. The study was completed in collaboration with a community-based residential treatment program located in Canada. A realist evaluation was conducted using qualitative interviews (N = 27) with program stakeholders. Transcripts were analyzed using thematic analysis to identify Context-Mechanism-Outcome (CMO) configurations that create the program theory. The analysis identified an overarching organizational context and 11 CMO configurations that comprise the program theory. The CMOs were grouped into three themes (i.e. relational, psychological, and diversity), underscoring the multiple pathways in which recovery is achieved for individuals with SUDs. Across the themes, the importance of building peer recovery relationships, creating structure, and inter-agency collaborations were highlighted. The results of the present study offer a contribution to the literature in understanding how, why, and for whom community-based residential treatment for SUDs is effective while offering specific recommendations to best tailor treatments to individuals.

Substance Use, Military Experience, and Posttraumatic Stress Disorder among Veterans in Community-Based Residential Treatment

This study examines the extent to which alcohol and drug use before military services is associated with post-service alcohol and drug use and symptoms of posttraumatic stress disorder (PTSD) among veterans in residential treatment. Face-to-face interviews were conducted with veterans in a major residential treatment center in New York City; 121 veteran patients participated in the study, with a 4% refusal rate. Premilitary service alcohol use tends to associate only with post-service alcohol use and preservice drug use only with postservice drug use; postservice use of alcohol is more closely correlated with PTSD symptoms than the use of drugs. Findings suggest that military culture of alcohol use should be taken into consideration when examining substance use and PTSD conditions among veterans and be included as part of the substance use disorder assessment.

“A scarlet letter”: Stigma and other factors affecting trust in the health care system for women seeking substance abuse treatment in a community setting

Background: Trust in health care has been shown to influence health care utilization, perceptions of fair treatment, and health outcomes in the general population. The literature on trust in health care in individuals with a history of substance use disorder (SUD) is more limited, primarily examining the patient-provider relationship. Women seeking substance abuse treatment in community-based programs have higher rates of prior trauma and health disparities compared with male counterparts and the general population. With higher rates of prior trauma, this population is theoretically at high risk of decreased interpersonal trust and altered interpersonal relationships. Objective: This study sought to identify factors influencing trust in the health care system for women seeking substance abuse treatment in a community-based residential treatment program. Methods: Six client focus groups (n = 30), 1 provider focus group (n = 7), and 2 individual clinical administrator interviews (n = 2) were conducted between November 2016 and August 2017. Focus groups and interviews were audio recorded and transcribed. Coding and coding reconciliation were conducted by 2 independent coders. Themes were extracted and analyzed from sorted and coded quotes. Results: Six themes emerged. Factors that influence trust in the health care system in this population include (1) prior experiences with diagnosis, treatment, and outcomes; (2) stigma of addiction; (3) payment and reimbursement structure; (4) patient rights and protections; (5) efficiency-driven care; and (6) the health care system's role in causing and/or enabling addiction. Conclusions: These themes demonstrate a general distrust of the health care system by women in this population. Distrust is influenced by a perception of a health care system providing care that is variable in quality, often stigmatizing, unaffordable, efficiency driven, and often influencing individuals’ SUD. This aligns with and extends prior literature around trust of health care in individuals with SUD. Future directions in research include formally assessing the impact of trust on health outcomes such as treatment entry and retention.

Predicting Repeated Child and Adolescent Residential Treatment Placements

ABSTRACTRepeated child and adolescent mental health residential treatment placements are important given such patterns can indicate inefficient and costly services, system of care imbalances and/or earlier treatment failure. Identifying factors that predict subsequent residential treatment placement at the same or more restrictive level of care can help the field consider assessment and intervention approaches to lessen multiple placements. The current study examined predictors of youth returning to the same or higher (more restrictive) level of care (vs. those who were successfully transitioned to home-based services) after an initial episode of community-based residential treatment. Although multiple variables predicted subsequent residential treatment placement, when entered together in a multiple logistic regression, younger age, the presence of an internalizing diagnosis (often with one or more externalizing diagnoses), rural facility location, and an unsuccessful discharge status from the initial residential treatment placement predicted greater likelihood of subsequent placement. Research and practice implications are discussed.

Effectiveness of an Intervention for Improving Intrinsic Motivation among Adolescent Males in a Secure Substance Use Treatment Setting

Because intrinsic motivation affects substance use treatment engagement and outcomes, interventions to increase readiness for change are needed. The Treatment Readiness and Induction Program (TRIP) effectively increases intrinsic motivation among youth in community-based residential treatment, but its utility for youth in secure settings is unknown. The current study uses a sequential comparison design to examine the added benefit of TRIP over standard operating practice (SOP) among 125 male adolescents in a juvenile justice treatment facility. Youth receiving TRIP in addition to SOP showed greater increases in problem recognition and desire for help, were three times more likely to want help for emotional problems, and were four times more likely to want individual counseling. Relationships remained after controlling for age and race; however, desire for help was not significant after controlling for substance use severity. Findings document the effectiveness of TRIP for promoting readiness among adolescent males in a secure treatment setting.

A Multi-Dimensional Conceptual Framework for Trauma-Informed Practice in Addictions Programming

ABSTRACTPrevious research has conceptualized trauma-informed practice in relation to five key values: safety, trust, choice, collaboration, and empowerment. This research identifies key organizational, programmatic, and interpersonal characteristics in community-based residential addictions treatment programming that exemplify each of these principles. Utilizing qualitative research methods, involving open-ended, one to one interviews with clients in residential substance misuse treatment (n = 41), respondents identified the importance of experiencing “safety” in relation to physical safety, confidentiality, reassurance, rule enforcement, and peer relationships. “Trust” was manifested in sharing, staff availability, nonjudgmental interactions, positive relationship dynamics, and caring. “Choice” was articulated in relation to individual needs, participation, opportunities, and focus of efforts. “Collaboration” was characterized in relation to opportunities for feedback, planning, goal setting, specificity, and support. Finally, “empowerment” was characterized by comfort in sharing, trigger management, trauma awareness, and understanding. The findings provide a conceptual framework for a trauma-informed social services organizational practice environment. Findings can inform adaptations to social service delivery processes and programs to become aligned with the values of trauma-informed practice. Future research can build on this framework by testing the study findings with quantitative methods along with replicating current methods in other social service delivery sectors.

Recommendations for Inpatient Psychiatric Treatment for Suicidal Adolescents

There is a great need for research that would provide empirical support for interventions and approaches to acute care that reduce the morbidity and mortality of suicide-related thoughts and behaviors in adolescents (Corcoran et al., 2011). The treatment adolescents currently receive on inpatient psychiatric units is sub-par, and this is not due to the experience and skills of clinicians, but rather, the larger system of psychiatric care in the United States. When parents agree to psychiatric hospitalization for their adolescents, they typically believe their adolescents will receive treatment at these units. However, rather than receive the active treatment they need on these units, they are essentially held there until they are “stable enough” to receive community-based residential treatment or outpatient treatment. This is an extremely ineffective way to treat adolescents with active suiciderelated thoughts and behaviors. Why not take advantage of the time when they are in crisis to deliver evidence-based treatments in brief formats but intensive doses? Currently, there are no evidence-based psychiatric inpatient treatments that have been found to reduce the frequency of suicide-related behaviors or suicide attempts subsequent to discharge (Knesper, 2010). Therefore, there is a critical need for the development and testing of brief, but intensive, treatments that can be delivered in acute psychiatric care settings (Knesper, 2010).

Correspondence Between the Psychopathic Personality Inventory and the Psychopathic Personality Inventory-Revised: a Look At Self-Reported Personality Traits

The authors examined the correspondence between the Psychopathic Personality Inventory (PPI) and a recent revision of this measure, the Psychopathic Personality Inventory—Revised (PPI-R) in a sample of 85 male and female offenders in a community-based residential drug treatment program. Participants completed the PPI and PPI-R along with self-report measures of narcissism, aggression, emotional intelligence, and negative emotionality. Analyses focused on the associations between the total and factor scores, as well as content scale scores across the two measures, and the similarity between parallel indices from these measures in their associations with external criteria. Results suggest that findings from prior research examining PPI associations with criterion measures in the self-report domain of personality traits can reasonably be generalized to the PPI-R.

Research Challenges: Implementing Standardized Outcome Measures in a Decentralized, Community-based Residential Treatment Program

With residential treatment services under pressure to produce outcome data, the process of executing research in such settings presents considerable challenges. This paper describes how a large, decentralized, community-based residential treatment program in southern and central Maine designed and implemented a research outcome process study using standardized measures on a variety of dimensions. The study’s rationale, process, challenges and findings are presented. Results indicated that the challenges to this work were minimized due to careful planning and collaboration by and with administration and treatment staff. Unique to this work was the process where a formal research approach was used in the context of a private, geographically diverse organization.

Patient Outcome after Treatment in a Community-Based Crisis Stabilization Unit

Community-based residential treatment for acute psychiatric crisis has been proposed as an alternative to inpatient hospitalization, but there is a dearth of adequate outcome studies. We examined naturalistic symptomatic and treatment outcomes in patients admitted to a residential crisis treatment program. The 24-item Brief Psychiatric Rating Scale score dropped from moderately ill (40.5 +/- SD 8.25 points) on admission to mildly ill at discharge (28.7 +/- 11.37 points, t = 10.02, P < 0.0001). Beck's Depression Inventory also improved greatly, from a significant level of depression of 29.5 +/- 11.41 points on admission, to a nearly euthymic level of 10.1 +/- 8.60 points at discharge (a difference of 19.4 +/- 12.10 points, t = 12.5, P < 0.0001). The current study is limited by the lack of a matched comparison group of hospitalized patients. Nonetheless, community-based crisis stabilization units appear to be cost-effective alternatives to inpatient hospitalization for selected patients.

Outcomes in Community-Based Residential Treatment and Rehabilitation for Individuals with Psychiatric Disabilities: A Retrospective Study.

This study evaluated outcomes for participants of a community-based residential treatment and rehabilitation program. The study used repeated measures to retrospectively evaluate 25 individuals with severe psychiatric disabilities who completed a 1-year follow-up period after discharge from the program. Results indicated that following the program these individuals lived for significantly longer periods in the community in more independent settings and functioned at higher levels than in the 6 years prior to participation in the program. These positive outcomes suggest that residential treatment and rehabilitation may be an important consideration in the care of some individuals with severe psychiatric disabilities.

The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders

This study compared assertive continuing care (ACC) to usual continuing care (UCC) on linkage, retention and a measure of continuing care adherence. Outcome analyses tested the direct and indirect effects of both conditions and level of adherence on early (months 1-3) and longer-term (months 4-9) abstinence. Two-group randomized design. Eleven counties surrounding a community-based residential treatment program in the Midwestern section of the United States. A total of 183 adolescents, ages 12-17 years, with one or more Diagnostic and Statistical Manual version IV (DSM-IV) substance use dependence disorder and met American Society for Addiction Medicine (ASAM) placement criteria for non-medical residential treatment. Prior to discharge from residential treatment, participants were assigned randomly to receive either UCC, available at outpatient clinics in the 11-county study area, or ACC via home visits. Self-reported interview data were collected at intake, 3, 6 and 9 months post-residential discharge. Urine test data and interviews with a caregiver were conducted at baseline and 3 months. ACC led to significantly greater continuing care linkage and retention and longer-term abstinence from marijuana. ACC resulted in significantly better adherence to continuing care criteria which, in turn, predicted superior early abstinence. Superior early abstinence outcomes for both conditions predicted longer-term abstinence. ACC appears to be an effective alternative to UCC for linking, retaining and increasing adherence to continuing care. Replication with larger samples is needed to investigate further the direct and indirect effects of ACC found in this study

The teaching-family model and post-treatment recidivism: A critical review of the conventional wisdom.

Conventional wisdom suggests that the Teaching-Family Model (TFM) approach to treating youthful offenders is not effective in reducing post-treatment recidivism. This article reviews two major studies referenced in support of this widespread perception. Data presented in one widely referenced study are treated with a Cochran-Mantel-Haensel test, which, the author argues, is appropriate for data originally presented in two separate 2 X 2 tables (one for boys and one for girls). The construct and statistical conclusion validity of a major evaluation study presented to the NIMH is critically evaluated and discussed. A revised view of the leading TFM evaluations has implications for public policy regarding juvenile justice. The author suggests that a belief in the lack of post-treatment efficacy associated with community-based residential treatment has resulted in harsher treatment of juveniles and a higher incarceration rate.

A Benefit-Cost Analysis of the Kings County District Attorney's Office Drug Treatment Alternative to Prison (DTAP) Program

In October 1990, the Kings County (Brooklyn, NY) District Attorney's Office implemented the Drug Treatment Alternative to Prison (DTAP) program to divert nonviolent felony drug offenders from prison to community-based residential drug treatment. This article presents an estimate of the costs and benefits of the DTAP program based on a cohort of DTAP participants and prison comparisons who entered treatment or prison in 1995–1996 and were tracked for 6 years. The analysis focuses on the criminal justice system (CJS) costs associated with criminal recidivism. Findings show that the DTAP program is cost-beneficial compared to the usual criminal justice process (benefit-cost ratio equals 2.17 after 6 years).

Pregnant, Substance-Abusing, and Incarcerated: Exploratory Study of a Comprehensive Approach to Treatment

Interventions addressing the multiple needs of incarcerated women are rare. In this study, several measures were used to assess functional changes among pregnant, substance-dependent, incarcerated women transferred to a community-based residential treatment program that allowed their infants to reside with them. Women engaged in comprehensive therapeutic and skill-building activities for 6 to 9 months. The program's goal was to assist women in childbirth and in the continuing relationship with their child while improving psychological and social functioning. Examination of changes were limited to those who completed treatment and all measures (n = 27). Although significant improvements were noted, nearly half were discharged with symptoms indicative of a depressive disorder. Assessment of long-term outcomes comparing this group with pregnant women who remained in prison is under way.

Is community-based treatment an add-on or a substitution for hospital treatment of alcoholism? Some evidence from Canada.

This study determined whether the development of community treatment of alcohol problems acted as an add-on or a substitution for the utilization of inpatient hospital services in Ontario. Complex modelling and graphic analyses using econometric multiple regression techniques were performed on data for the 48 counties of Ontario (Canada) for the period 1972 to 1988, combining both cross-sectional and time series analysis. After controlling for differences in alcohol consumption, in health care characteristics such as the supply of physicians or hospital occupancy rates, and in socioeconomic characteristics of the population, when community treatment became available, hospital utilization for the treatment of alcohol problems decreased and community services were substituting for hospital treatment. In addition, nonresidential services had an overall greater importance in producing this effect (elasticities at the mean of -0.11 to -0.14 depending on the region) than community-based residential treatment. The effect was larger in the southern than in the northern counties of Ontario. Testing of the modelling techniques showed statistically significant and satisfactory modelling of the forces at work. Where community-based treatment was available, it was used in preference to inpatient hospital treatment; however, there may be a slightly more complex relationship present in the southern urban counties (which contain the larger metropolitan areas) than in the northern and southern rural counties..

In whose 'best interests'? Ethical issues involved in the moral dilemmas surrounding the removal of sexually abused adolescents from a community-based residential treatment unit to a locked, forensic adult psychiatric unit.

This study scrutinizes the ethical and moral dilemmas surrounding the removal of sexually abused adolescents from a community-based residential treatment unit to a locked, forensic adult psychiatric unit. Adolescent victims of sexual abuse exhibit a plethora of psychopathological symptomatology which can lead in many cases to the adolescent resorting to self-injurious behaviours in an attempt to relieve feelings of tension, anxiety and guilt. Because the unit in which the writer is involved is an open, community-based treatment centre with limited staffing levels, a completely secure environment may be compromised. Consequently self-injurious adolescents may become so disturbed that a more secure environment must be sought. The limited resources for disturbed adolescents in Northern Ireland means that occasionally the only option available to health care professionals who find themselves in this situation is to utilize the services of the psychiatric adult, forensic unit in Belfast which is contained within a large psychiatric hospital. Many would agree that such a placement for a disturbed adolescent seems inappropriate but is at the same time unavoidable. This study will examine the ethical and moral minefield that only recently has become a dilemma for health care professionals and particularly for nurses endeavouring to adhere to the code of professional conduct.

Cross-cultural replication and evaluation of the teaching family model of community-based residential treatment

Cross-cultural replication and evaluation of the teaching family model of community-based residential treatment

A Model Treatment Program Closes—

An analysis of the closing of a model community-based residential treatment program using research on change, conflict and organizational behavior is offered to suggest that problems in the implementation phase of a policy change should not be erroneously anributed to the merits of the policy itself, and that a potentially destructive conflict can result from a service provider attempting to also play a change agent/advocacy role.

Developing an inservice training curriculum for child and youth care workers in community-based residential treatment: A process analysis

The current paper describes the process by which an inservice training curriculum was developed by a universe (15) of community-based residential treatment programs. The programs were independently operated and often geographically isolated. A wide variety of treatment philosophies were represented: teaching-family model, psychodynamic, re-education, and eclectic. Offered in a twelve-month, three-phase format, the inservice training program (how the curriculum is to be taught) is presented.