Long-term Residential Treatment Research Articles

Arguments against the compulsory treatment of opioid dependence

The Asian Network of People Who Use Drugs finds a recent attempt to advocate for compulsory “rehabilitation” centres1 founded on faulty arguments and dubious research that, if heeded, poses a direct threat to the human rights of people who use drugs and the dignity of society at large. Wu’s round table article claims to refute the rationale behind the recent call made by 12 UN agencies “… to close compulsory detention and rehabilitation centres and implement voluntary, evidence-informed and rights-based health and social services in the community”.2 In countries with compulsory centres, the detention of people who use drugs often occurs without sufficient due process, legal safeguards or judicial review, and there are frequent reports of physical and sexual violence, forced labour, sub-standard conditions, denial of health care, and other violations of human rights in such state-sanctioned centres.3 Yet Wu claims “… there is no evidence that people in such centres are at higher risk of opioid-related medical complications, infectious diseases or death, than those not living in compulsory treatment centres”. A 2010 report – one of many exposes – on compulsory drug treatment and forced labour shows that such centres deny access to treatment, put inmates at risk of physical abuse and forced labour.4 To imply that such unacceptable conditions may also exist in the community is the weakest possible defence for favouring compulsory centres. The article suggests that we “… must take into account both the human rights of the opioid-dependent individuals and those of the people who live in their communities”, omitting the fact that deprivation of liberty without due process is always an unacceptable violation of human rights.5 When the rights of drug-using individuals have been compromised for community well-being, these measures have both failed to improve communities and forced people who use drugs further underground, encouraging needle-sharing and other risky behaviours.6,7 State-sanctioned violence always reflects badly on society as a whole, not least in Asian countries that identify as community-oriented. Wu proposes – and the discussants disagree – that compulsory centres make the community safer from violent criminals. Yet studies show that “… many dependent drug users do not commit any crimes other than drug use/possession, where it is criminalized”.8 Evidence also shows that low threshold treatments such as methadone maintenance programmes reduce involvement in crime.9 Wu proposes that: “Compulsory treatment centres should be part of a broader harm reduction strategy.” The UN system has recommended nine essential services for people who inject drugs, all of which have a strong evidence base and none of which sanction compulsory treatment.10 Compulsory drug rehabilitation centres have not shown to be effective in preventing relapse and they pose considerable risks to the well-being of detainees.11,12 The UN Special Rapporteur has reported on abuse, torture, cruel and inhumane treatment and degrading punishment in health-care settings. With regard to mandatory drug treatment, the report states: “… State drug policies intentionally subject large groups of people to severe physical pain, suffering and humiliation, effectively punishing them for using drugs and trying to coerce them into abstinence, in complete disregard of the chronic nature of dependency and of the scientific evidence pointing to the ineffectiveness of punitive measures.”13 The UN office for Drugs and Crime further reminds us that: “Many countries provide long-term residential treatment for drug dependence without the consent of the patient that is in reality a type of low security imprisonment. Evidence of the therapeutic effect of this approach is lacking, compared to traditional imprisonment and community based involuntary drug treatment. It is expensive, not cost-effective, and neither benefits the individual nor the community.”14 We argue that compulsory drug centres fail in their stated aim of achieving abstinence and that the points made in favour of the centres do not amount to any rational excuse for keeping them open. The Asian Network of People who Use Drugs reaffirm our call for relevant states to close down compulsory drug detention centres, and for the UN system to rigorously discourage their continuation. We also offer our network as a resource for governments wishing to implement services that have been proven to reduce crime as well as improving health and human rights for people who use drugs.

Disadvantageous Decision-Making as a Predictor of Drop-Out among Cocaine-Dependent Individuals in Long-Term Residential Treatment

Background: The treatment of cocaine-dependent individuals (CDI) is substantially challenged by high drop-out rates, raising questions regarding contributing factors. Recently, a number of studies have highlighted the potential of greater focus on the clinical significance of neurocognitive impairments in treatment-seeking cocaine users. In the present study, we hypothesized that disadvantageous decision-making would be one such factor placing CDI at greater risk for treatment drop-out.Methods: In order to explore this hypothesis, the present study contrasted baseline performance (at treatment onset) on two validated tasks of decision-making, the Iowa Gambling Task (IGT) and the Cambridge Gamble Task (CGT) in CDI who completed treatment in a residential Therapeutic Community (TC) (N = 66) and those who dropped out of TC prematurely (N = 84).Results: Compared to treatment completers, CDI who dropped out of TC prematurely did not establish a consistent and advantageous response pattern as the IGT progressed and exhibited a poorer ability to choose the most likely outcome on the CGT. There were no group differences in betting behavior.Conclusion: Our findings suggest that neurocognitive rehabilitation of disadvantageous decision-making may have clinical benefits in CDI admitted to long-term residential treatment programs.

Quality of object representations related to service utilization in a long-term residential treatment center.

The current study examines patient factors related to service utilization during intensive treatment for 66 residential patients suffering from severe mental illness. We examined the relationship among demographic, psychiatric severity, and quality of object representation variables with individual and group psychotherapy sessions attended and emergency department transfers. Hierarchical linear regression models indicate malevolent affective expectations of interpersonal relationships embedded in patient narratives is uniquely related to individual psychotherapy attendance. A three-variable model consisting of higher educational status, number of axis I/II disorders, and poor understanding of social causality was related to transfers to emergency departments owing to self-destructive behavior. Quality of object representation of self and others was uniquely related to treatment use and self-destructive behaviors. Results highlight the importance of a comprehensive multimodal evaluation for improving treatment preparation, planning, and intervention. Clinical implications are considered.

Long-term residential substance abuse treatment for women: lessons learned from Israel

BackgroundPolicymakers and treatment providers must consider the role of gender when designing effective treatment programs for female substance abusers. This study had two aims. First, to examine female substance abusers’ perceptions regarding factors that contribute to their retention (and therefore positive treatment outcomes) in a women-only therapeutic community in Northern Israel. Second, to explore pretreatment internal and external factors including demographic, personal and environmental factors, factors associated with substance use and with the treatment process, and networks of support that contribute to retention and abstinence.MethodsThe study was a conducted using a mixed methods approach. Semi-structured qualitative interviews examining perceptions towards treatment were conducted in five focus groups (n = 5 per group; total n = 25). Intake assessments and a battery of questionnaires examining pretreatment internal and external factors related to treatment retention and abstinence were collected from 42 women who were treated in the program during the 2 year study period. Twenty-three women who completed the 12 month program were compared to the 19 women who did not, using chi-square for categorical variables and t-tests for continuous variables. Nineteen of the 23 women who completed the questionnaires also completed a post-treatment follow-up questionnaire.ResultsA content analysis of the interviews revealed five central themes: factors associated with treatment entry; impact of treatment in a women-only setting; significant aspects of treatment; difficulties with the setting; prospects for the future. Analysis of the questionnaires revealed that compared to non-completers, completers had fewer psychiatric symptoms, higher levels of introverted behavior in stressful situations, a better sense of coherence, and less ability to share emotions. No significant differences were found with regard to demographic and substance use factors. All 19 women who completed treatment and the follow-up questionnaire remained abstinent from illicit drugs for 18 months following the end of treatment.ConclusionResults indicate that women see the women-only treatment setting as extremely significant. Also, there is a profile of psychiatric co-morbidity, extrapunitiveness, and fewer personal resources that predict a risk for attrition. Thus, women at risk for attrition may be identified early and treatment staff can utilize the results to assist clients in achieving their treatment goals. Results can inform policymakers in making decisions regarding the allocation of resources, by pointing to the importance of long-term women-only residential treatment in increasing positive treatment outcomes.

Cue-elicited heart rate variability and attentional bias predict alcohol relapse following treatment

Identification of malleable neurocognitive predictors of relapse among alcohol-dependent individuals is important for the optimization of health care delivery and clinical services. Given that alcohol cue-reactivity can predict relapse, we evaluated cue-elicited high-frequency heart rate variability (HFHRV) and alcohol attentional bias (AB) as potential relapse risk indices. Alcohol-dependent patients in long-term residential treatment who had participated in mindfulness-oriented therapy or an addiction support group completed a spatial cueing task as a measure of alcohol AB and an affect-modulated alcohol cue-reactivity protocol while HFHRV was assessed. Post-treatment HFHRV cue-reactivity and alcohol AB significantly predicted the occurrence and timing of relapse by 6-month follow-up, independent of treatment condition and after controlling for alcohol dependence severity. Alcohol-dependent patients who relapsed exhibited a significantly greater HFHRV reactivity to stress-primed alcohol cues than patients who did not relapse. Cue-elicited HFHRV and alcohol AB can presage relapse and may therefore hold promise as prognostic indicators in clinical settings.

Outcomes for Adolescent Girls After Long-Term Residential Treatment

Residential treatment for troubled adolescents continues to generate controversy. Youth may improve during treatment, but are these gains sustained upon return to the community? We explore this question by analyzing outcome data collected at three months and one year post-discharge for 49 adolescent girls discharged from long-term programs at a residential treatment center in Massachusetts. Qualitative data reveals the range of post-discharge challenges experienced by adolescents and their families. Quantitative data shows a 77% reduction in restrictive level of care placements comparing the year before admission to the year after discharge (p < .001). This success rate suggests that improvements accomplished during long-term residential treatment are sustained by a majority of adolescent girls up to at least one year post-discharge. We will also discuss the process we used to collect outcome data and its impact on our agency staff and clientele.

Improving addictions treatment outcomes by empowering self and others

The present research tested the effectiveness of adding an interpersonal, interactive, experiential training programme to addictions treatment that enhances motivation, cognitive-behavioural coping skills, social support, and group cohesiveness. The research was conducted in a co-educational, long-term residential treatment facility for addictive disorders (alcohol and other substances, sexual addiction, eating disorders, compulsive shopping, and gambling) and concomitant psychiatric diagnoses. The added training is co-created by participants. They choose challenging situations important in their lives that are played out as 'movies' in which they play and experience all the parts. Motivation for change, skills to implement positive changes, self-efficacy, empathy, positive support, and group cohesiveness are rooted in their own experiences and the feedback they receive from others, as they behave in empowering and disempowering ways. The training resulted in significant increases in empowering communication, self-esteem and quality of group life in the treatment group and in the family. Many of these results have large effect sizes and are consistent with the findings from prior studies. The results obtained in this study suggest that Say It Straight training can be an effective addition to the treatment of addictions in residential treatment. Future research is needed to determine the long-term effects of this training on relapse.

The Haven Mother's House Modified Therapeutic Community: Meeting the gap in infant mental health services for pregnant and parenting mothers with drug addiction.

The specialized needs of pregnant and parenting women in the treatment of drug addiction must not be underestimated. The impact of substance abuse on developmental outcomes for young infants and children supports the notion that attention to the parent-child relationship is a critical aspect of addiction treatment for this population. As such, the standard of care appears to be shifting from separating mothers and young children while the mother completes addiction treatment to women residing with their children while in treatment and receiving concurrent addiction treatment and parenting education. While parenting education is important, it may not provide the needed relationship intervention to address the myriad of issues often present for female recovering addicts and their children. This article describes the evolution and workings of a program for integrating infant mental health practice into a long-term residential treatment community for pregnant and parenting women with addiction. The principles and structure of the modified therapeutic community are described, as are the ways in which infant mental health practice have been effectively integrated and incorporated into the addiction treatment philosophy. A case example is provided, and clinical implications are discussed.

Matching to Sufficient Treatment: Some Characteristics of Undertreated (Mismatched) Clients

ABSTRACT A previous study by the investigative team using Drug Abuse Outcome Study data supported the validity of a sufficient treatment matching paradigm, which defines successful placement as the least treatment intensity required to address the severity of a disorder. The least favorable outcomes were obtained in the under-treated clients who received insufficient treatment intensity. The purpose of the current study was to further clarify characteristics of the undertreated clients. Four groups, those matched and mismatched to long-term residential (LTR) and drug-free outpatient (ODF) treatment, were compared on several baseline variables. Results indicated that the severity levels of drug use, social and psychological problems, and motivation for those mismatched to ODF (undertreated) were significantly lower than the clients matched to LTR but generally higher than the clients matched to ODF and those mismatched to LTR (overtreated). These findings underscore the importance of identifying clients at risk for under-treatment and facilitating their entry into treatments of sufficient intensity. More generally, they highlight the need to develop a range of treatment options of sufficient intensity to meet severity differences among clients.

The Washington Circle continuity of care performance measure: Predictive validity with adolescents discharged from residential treatment

This study examined the predictive validity of the Washington Circle (WC) continuity of care after long-term residential treatment performance measure, as well as the impact of assertive continuing care interventions on achieving continuity of care. This measure is a process measure that focuses on timely delivery of a minimal floor of services that are necessary to provide sufficient quality of treatment but should not be construed to be the optimal continuity of care after residential treatment for any specific adolescent. Participants included 342 adolescents who were admitted to long-term residential treatment and randomly assigned to either standard continuing care or an assertive continuing care condition. Overall, results provide initial support for the WC continuity of care after residential treatment performance measure as a useful predictor of 3-month recovery status. In addition, assignment to an assertive continuing care condition was found to significantly increase the likelihood of achieving continuity of care.

Factors associated with retention in a long-term residential rehabilitation programme for women with substance use problems

Background: Retention in substance abuse treatment is difficult but essential for positive post-treatment outcomes. Aims: The present study is the first to explore factors related to retention in a long-term specialist residential substance abuse treatment programme for women in Australia. Methods: Archival data (e.g. socio-demographic, substance use, mental health, and length of stay) were collected from a sample of 71 women admitted to the programme between January 1997, and November 2002. Participants were divided into two groups based on their length of stay in the programme: less than 90 days (n = 42) and 90 days or more (n = 29). Results: A substantial proportion of the sample experienced comorbid substance abuse and mental health problems, with 60.6% (n = 43/71) reporting evidence of comorbidity (either a previous psychiatric diagnosis, or having been prescribed psychiatric medications). Overall, only 13% of residents completed the programme. Longer retention was associated with demographic (older ...

Community-Based Psychodynamic Treatment Program for Severe Personality Disorders: Clinical Description and Naturalistic Evaluation

Long-term inpatient treatment for personality disorders has become infrequent in the last two decades, and the gap left in service provision has been filled by psychodynamically and cognitively oriented partial hospitalization and outpatient, community-based approaches. It is still uncertain how these low-cost, lower-intensity models have fared relative to residential models that treat patients with severe personality disorders with the containment and control offered by the inpatient setting. In this article, we describe key features of a community-based psychodynamic program developed at the Cassel Hospital in the United Kingdom and present preliminary findings of a 2-year prospective naturalistic outcome study that monitored psychiatric morbidity (Brief Symptom Inventory General Severity Index [BSI-GSI]) and clinical outcome (self-mutilation, suicide attempts, and hospital admissions) in 68 patients with personality disorders who were consecutively admitted to the program. Improvements shown by the community-based sample on all variables were compared with the results in a comparable sample of inpatients treated in a long-term psychosocial treatment program in the same institution. The naturalistic comparison of the two non-randomized treatment models revealed that the community-based sample improved to a significantly greater degree on all three clinical outcome dimensions and had significantly lower early dropout rates than those who received the long-term residential treatment. The findings indicate that, at least in terms of impulsive behavior and treatment adherence, the community-based program appears to offer a viable adequate alternative to long-term inpatient admission.

Client Matching: A Severity-Treatment Intensity Paradigm

ABSTRACT Despite considerable effort to develop matching strategies and client placement protocols, research studies fail to yield compelling results regarding the benefits of matching to treatment. The most consistent findings suggest a matching paradigm, which defines a successful placement as the least treatment intensity required addressing the severity of the disorder. The purpose of the present study is to provide further empirical support for the validity of a severity-intensity paradigm utilizing data from the Drug Abuse Treatment Outcome Studies. A “passive match” approach employed the Client Matching Protocol decision algorithm, which recommended clients to long-term residential or outpatient drug-free treatment. One-year outcomes for clients matched to long-term residential treatment were better on all outcome variables compared to those undertreated in outpatient drug-free treatment. Findings supported the validity of the severity-intensity paradigm in that undertreated clients showed less improvement compared to matched and overtreated clients.

Predictors of Retention in an Alternative-To-Prison Substance Abuse Treatment Program

This longitudinal study examines predictors of retention among alternative-to-prison substance abuse treatment clients. The roles of motivational factors and the client-therapist relationship are examined. The sample was composed of 141 male felony offenders who were legally mandated to a community-based, long-term residential drug treatment program. Results support the following conclusions: (a) retention in treatment is positively related to motivation to change; (b) motivation to change, particularly recognition of a drug problem, is positively related to the therapeutic alliance; and (c) changes in motivation in response to treatment are positively related to the therapeutic alliance. Implications of these findings for treatment and research are discussed.

Health-Related Quality of Life Among Substance Abusers in Residential Drug Abuse Treatment

Health-related quality of life (HRQOL) in substance abusers remains an area of inquiry in need of investigation. The few studies on the topic have found substance abuser HRQOL less than that of the general population. The present research compared 303 substance abusers in long-term residential therapeutic community treatment in New York with a general non-institutionalized adult sample from New York (N = 27,465) whose data were collected between 2002 and 2006 during the yearly administrations of the Behavioral Risk Factor Surveillance System (BRFSS), a state-based system of health surveys gathering data from upwards of 350,000 adults per year across all 50 states. One sample t-tests found that the in-treatment substance abusers reported significantly more physically and mentally unhealthy days over the past 30 days, as well as significantly more inactive days over the past 30 days due to illness.

List of Referees - 2007

In Brazil, regarding drug and alcohol treatment, there is an emphasis on financing long-term residential treatment and a lack of community-based approaches, leading to a burden on families. Therefore, family members increasingly seek coerced treatment even though there are reports of human rights violations in this context. This study aims to describe the meanings constructed by family members regarding coerced treatment of people who use alcohol and other drugs.We conducted 15 interviews with the family members of people who use alcohol and other drugs and had requested coerced treatment. The interviews were recorded, transcribed and analyzed using reflexive thematic analysis.Through analysis, five major themes regarding the use of coerced treatment were constructed: (1) as protection for people from the dangers related to the use of alcohol and other drugs; (2) as punishment, aiming to prevent the return to drug use; (3) as a guarantee of abstinence; (4) as a consequence of the loss of autonomy to decide what was best for themselves; and (5) as time for the reorganization of the family members’ lives. The lack of emotional support in relation to their concerns regarding the health and safety of the person using drugs, the prohibitionist discourse and the emphasis on abstinence shared in the decision to seek coerced treatment, and the lack of knowledge about voluntary treatments contributed to family members requesting coerced treatment more than once.This study highlights the importance of the need for public policies that expand evidence-based voluntary approaches, especially community-based services, and promote the disclosure of these services to eliminate coerced treatment. Health care providers should support the feelings of family members and provide guidelines related to other treatment options, making families feel genuinely included as partners in the care of people who use drugs.

Treatment programs in the National Drug Abuse Treatment Clinical Trials Network

Drug abuse treatment programs and university-based research centers collaborate to test emerging therapies for alcohol and drug disorders in the National Drug Abuse Treatment Clinical Trials Network (CTN). Programs participating in the CTN completed Organizational Surveys ( n = 106 of 112; 95% response rate) and Treatment Unit Surveys ( n = 348 of 384; 91% response rate) to describe the levels of care, ancillary services, patient demographics, patient drug use and co-occurring conditions. Analyses describe the corporations participating in the CTN and provide an exploratory assessment of variation in treatment philosophies. A diversity of treatment centers participate in the CTN; not for profit organizations with a primary mission of treating alcohol and drug disorders dominate. Compared to National Survey of Substance Abuse Treatment Services (N-SSATS), programs located in medical settings are over-represented and centers that are mental health clinics are under-represented. Outpatient, methadone, long-term residential and inpatient treatment units differed on patients served and services provided. Larger programs with higher counselor caseloads in residential settings reported more social model characteristics. Programs with higher social model scores were more likely to offer self-help meetings, vocational services and specialized services for women. Conversely, programs with accreditation had less social model influence. The CTN is an ambitious effort to engage community-based treatment organizations into research and more fully integrate research and practice.

The influence of legal coercion on dropout from substance abuse treatment: Results from a national survey

Legal coercion is frequently used to leverage substance abuse treatment upon persons who would otherwise not seek it voluntarily. Various methodological and conceptual problems of the existing research have prevented a clear understanding of its effectiveness. The influence of legal coercion on retention in substance abuse treatment was examined using a national survey of programs in the public sector of care and three different treatment modalities including short-term residential ( N = 756 ), long-term residential ( N = 757 ), and outpatient treatment ( N = 1181 ). Legal coercion was found to reduce the risk of dropout across all three treatment modalities. The greatest effect was among persons in short-term residential treatment. The smallest effect was observed in outpatient treatment. This study shows that legal coercion significantly reduces the risk of dropout in substance abuse treatment. However, the differential effects across treatment conditions must be carefully considered when using coercion to involve individuals in treatment.

Outpatient Treatment Programs: A Review Article on Substances of Abuse Outpatients Treatment Outcomes in the United States

A number of treatment approaches and techniques have been developed and used for management of drug abuse and alcoholism during the last 50 years in the United States. These treatment methods have been categorized based on the treatment settings (outpatient, short-term residential, long-term residential) or based on treatment techniques [pharmacological or nonpharmacological (behavioral, psychosocial)]. The relative effectiveness and appropriateness of these treatments has always been an issue of concern to health policy, and decision makers, treatment providers and the users. For example, naltrexone, a long acting orally effective opioid antagonist, has been tried in patients of opioid or alcohol dependence. In controlled clinical studies, the drug has shown positive effects when added to counseling. It is reported to significantly reduce heavy drinking in patients who are willing to take the drug as prescribed. However, the beneficial effects of naltrexone are limited due to the serious problem of noncompliance or lack of willingness of patients to continue it for sufficient duration. Buprenorphine is an opioid agonist-antagonist effective for the treatment of opiate abuse besides its analgesic indication in patients with advanced painful cancer. Three national studies evaluating drug abuse treatment programs have been carried out to evaluate the suitability of the different outpatient treatment programs. However, methodological differences used in these programs have been a limitation to arrive at solid conclusions. Furthermore, the treatment modalities also varied as they evolved across time and change in their components. The client characteristics changed across last 3 decades particularly regarding the drug of abuse. The admission to specific treatment modalities depended on client criteria based on admission guidelines in force from time to time. These variations may limit the comparability of treatment outcome across these studies and across different treatment modalities, though adequate measures have been taken during analysis to minimize these limitations. Despite these limitations, some generalizations about the effectiveness of outpatient treatment can be made from the findings that have been consistent across studies. Outpatient drug-free treatment program is effective in reducing drug abuse and in improving other parameters like criminality and employment. Furthermore, it is effective as methadone maintenance; however, it is less effective than long-term residential treatment program. The program is effective primarily if patients receive treatment for 3 months or longer.

Rational Choice and Environmental Deterrence in the Retention of Mandated Drug Abuse Treatment Clients

Length of treatment stay is consistently associated with positive posttreatment outcomes in the rehabilitation of drug-abusing offenders. However, past retention research centered on the examination of individual-level determinants to the exclusion of environmental predictors. In this study, the authors propose a rational choice framework in which treatment retention is viewed as a decision-making process that involves calculation of costs and benefits of remaining in treatment. Environmental factors not directly related to the treatment process are theorized to either reward or punish the course of action taken by each treatment client. Retention data from 1,984 drug-abusing felons diverted for long-term residential treatment were analyzed to test the hypotheses that criminal sanctions against drug offenses, violence in local drug markets, and lack of legitimate job opportunities act as deterrents against premature termination of treatment. Results corroborated the criminal sanction and unemployment hypotheses, but not the violence hypothesis. These findings highlight the necessity of reinforcing perceptions of arrest risks and job prospects during treatment. The study concludes with some clinical recommendations.