Counseling frequency and the effectiveness of outpatient drug treatment: revisiting the conclusion that "more is better.".

Replicating and extending previous research, findings from a prospective investigation of outpatient drug treatment (n = 356) indicate that higher frequency of participation in group counseling during treatment predicts higher rates of alcohol and drug abstinence even for those who complete the 6-month treatment program and maintain weekly or more frequent attendance of 12-step meetings during and after treatment. Greater length of group and individual counseling sessions, however, is not associated with higher rates of abstinence, and contrary to previous research, the modest but statistically significant association between the frequency of individual counseling and abstinence was not replicated. With respect to treatment completion, regular attendance at 12- step meetings, and frequent participation in group counseling while in treatment, the evidence suggests that "more is better."

Self-efficacy, expectancies, and abstinence acceptance: further evidence for the addicted-self model of cessation of alcohol- and drug- dependent behavior.

The Addicted-Self Model of the cessation of alcohol- and drug-dependent behaviors is outlined briefly, and five hypotheses consistent with the predictions of the model are examined. All five hypotheses are confirmed, broadening the support for the Addicted-Self Model of recovery. These findings also suggest modifications of the assumptions underlying alcohol and drug expectancy research. These modifications are discussed, and directions for further research are suggested.

Exploring the additive effects of drug misuse treatment and Twelve-Step involvement: does Twelve-Step ideology matter?

Previous research revealed an additive effect of recovery activities in that those who attended Twelve-Step meetings on a weekly basis during and after outpatient drug-user treatment had higher rates of abstinence compared to those who participated in either treatment or Twelve-Step programs alone. The current investigation extends the previous research by examining the possible effects of Twelve-Step ideology on participation in Twelve-Step programs and abstinence from drug use. The findings from this treatment outcomes study indicate that the acceptance of Twelve-Step ideology, particularly strong agreement with the need for frequent, lifelong attendance at Twelve-Step meetings, and the need to surrender to a "higher power" are significant predictors of weekly or more frequent attendance at Twelve-Step meetings independent from other potentially mediating variables. Twelve-Step ideology, specifically the notion that controlled or nonproblematic drug use is not possible, predicted abstinence independent from Twelve-Step participation and other potentially mediating variables. These findings often a number of implications concerning group process and recovery from drug misuse which are addressed in the Discussion section under the following topics: 1) spirituality and group cohesion, 2) spiritual transcendence, social transcendence, and recovery; 3) spirituality and the obstruction of recovery; 4) Twelve-Step ideology and learning; 5) perceived control of drug use, self-efficacy theory, and recovery; and 7) perceived control of drug use and optimistic illusions. Directions for future research are discussed.

Drug treatment and 12-step program participation: the additive effects of integrated recovery activities.

The dramatic rise in the number of 12-step programs and participants raises questions concerning client participation in drug treatment and 12-step programs, and their separate and combined effects on recovery. The results of a treatment outcomes study indicate that rather than recovery alternatives, drug treatment and 12-step programs are utilized by the client as integrated recovery activities. Treatment participants with pretreatment 12-step involvement stayed in treatment longer, and were more likely to complete the 24-week program. Both pretreatment 12-step involvement and duration of participation in drug treatment are associated with subsequent 12-step involvement. Most importantly, there is an additive effect of these recovery activities in that those who participated concurrently in both drug treatment and 12-step programs had higher rates of abstinence than those who participated only in treatment or in 12-step programs.

Client engagement in drug treatment.

Client engagement in drug abuse treatment is associated with favorable treatment outcomes, but it is not completely understood why some clients are more likely to engage in treatment. This study examines a wide array of client characteristics and treatment experiences potentially associated with engagement. Findings from the Los Angeles Target Cities Project, funded by the Center for Substance Abuse Treatment, indicate that the predictors of treatment engagement are generally confined to current treatment experiences. For both women and men, the perceived utility of treatment, ancillary services, and the client-counselor relationship are the strongest predictors of client engagement in treatment. Client characteristics are generally not strong predictors of treatment engagement. Concerning the client-counselor relationship, the findings suggest that women may respond more favorably to an empathic counseling style, whereas men may respond to a more utilitarian style. The findings contradict popular stereotypes about the treatment-"receptive" client, identify possible directions for treatment improvement, and highlight the need for more research examining the treatment experience of the client. Other research, clinical, and policy implications are discussed.

After drug treatment: are 12-step programs effective in maintaining abstinence?

Although participation in 12-step programs is now widely utilized as a treatment aftercare resource by individuals with drug and alcohol problems, little is known about the effectiveness of such a practice. This paper identifies gaps in the existing literature and articulates methodological concerns that may compromise investigations of 12-step programs. It highlights the need for additional after-treatment studies, and it presents findings from a 24-month longitudinal after-treatment study that suggests the effectiveness of 12-step programs. Rather than a behavioral indicator of recovery motivation or a spurious relationship confounded by additional treatment, aftercare, or alumni activities that occur simultaneously with 12-step participation, the findings suggest that weekly or more frequent 12-step participation is associated with drug and alcohol abstinence. Less-than-weekly participation is not associated with favorable drug and alcohol use outcomes, and participation in 12-step programs seems to be equally useful in maintaining abstinence from both illicit drug and alcohol use. These findings point to the wisdom of a general policy that recommends weekly or more frequent participation in a 12-step program as a useful and inexpensive aftercare resource for many clients.

Drug treatment outcomes: investigating the long-term effects of sexual and physical abuse histories.

Individuals in drug treatment, particularly women, generally report high levels of past sexual and physical abuse. Although histories of sexual and physical abuse are associated with greater prevalence and severity of depression, anxiety, phobias, and interpersonal difficulties for individuals seeking substance-related treatment, several recent studies failed to show that prior sexual or physical abuse compromised short-term drug treatment outcomes. This study examined the possible effects of sexual and physical abuse on a wide array of behavioral domains over a two-year posttreatment period. The findings indicate few differences between those with and without past histories of such abuse in terms of drug use, drug treatment and 12-Step program participation, criminality, income sources, intimate relationships, family functioning, and psychiatric symptoms. There are specific exceptions, but they apply only to men. Overall, the findings indicate that the impact of sexual and physical abuse histories on relatively long-term treatment outcomes is minimal. Addressing the sexual and physical abuse histories of those seeking treatment for drug abuse may be justified on humanistic grounds, but it will not significantly improve the long-term effectiveness of drug treatment, nor will it substantially enhance the lives of those with histories of abuse.

Effective drug treatment. Testing the distal needs hypothesis.

A long-standing view held by many drug abuse treatment providers, researchers, and policy makers is that maximally effective drug treatment needs to attend to the employment, health, housing, and other "distal needs" of the client. This paper tests the distal needs hypothesis by determining the effects of resolved, unresolved, and emergent family, housing, health, legal, emotional, and vocational needs on treatment engagement and treatment outcomes. Findings from a prospective, longitudinal study of 330 clients in 26 outpatient programs in the Los Angeles metropolitan area indicate little support for the distal needs hypothesis. Specifically, those with unresolved or emergent distal needs were not less likely to engage in treatment or use drugs during and after treatment. Treatment and research implications of these findings are addressed.

Does increasing the opportunity for counseling increase the effectiveness of outpatient drug treatment?

Increasing the opportunity for group and individual counseling in outpatient drug treatment programs could increase client participation in counseling which, in turn, may enhance program effectiveness. Findings from the evaluation of the Los Angeles Target Cities Enhancement Project indicate that the Target Cities programs successfully increased client participation in group and individual counseling-an increase that cannot be attributed to client characteristics. Further, the magnitude of the increase in group and individual counseling was sufficient to increase the overall effectiveness of Target Cities programs. These findings support the widely held contention among drug treatment providers and policy makers that frequent counseling in necessary for treatment success. They suggest that counselors and other service providers should encourage and facilitate frequent participation in group and individual counseling. Most importantly, the findings indicate that increasing the opportunity for group and individual counseling will increase client participation in counseling, and this increased participation will elevate the overall effectiveness of outpatient drug treatment.

Sexual and physical abuse: do they compromise drug treatment outcomes?

Histories of sexual and physical abuse are frequently reported by individuals participating in substance abuse treatment, these experiences may be associated with psychopathology and poor drug treatment outcomes. This paper presents the findings from a longitudinal study of 330 subjects participating in 26 outpatient treatment programs. Sexual abuse among women was associated with higher levels of depression, anxiety, suicidal ideation, suicide attempts, and PTSD, while physical abuse was associated with fewer psychological disturbances. For men, sexual abuse was associated only with anxiety. Physical abuse was associated with depression, anxiety, suicidal ideation, and PTSD. However, no significant association was found between sexual and physical abuse, and lower levels of treatment participation or drug use at follow-up. These findings indicate that there is a complex connection between abuse, psychopathology, treatment participation, and relapse. Clinical and research implications of these findings are discussed.

Drug treatment: explaining the gender paradox.

There is something of a gender paradox in drug user treatment. Research consistently indicates that women possess "risk factors" associated with drug use relapse, yet women are no more likely, and possibly less likely, to relapse to drug use. Efforts to explain this paradox involve a longitudinal study of 330 women and men participating in outpatient drug-user treatment associated with the evaluation of the Los Angeles Target Cities Project funded by the Center for Substance Abuse Treatment. The findings offer no support for the drug severity and social support hypotheses, but some support for the treatment engagement hypothesis. Specifically, women participate more frequently in group counseling which, in turn, lowers their rate of relapse in spite of having more "risk factors." Further analyses indicate that the greater participation of women in group counseling does not stem from child-custody or other gender differences in the reasons for entering treatment, nor does it result from the enhanced services associated with the Target Cities Project. Rather, the differences in treatment engagement for women and men may result from gender norms concerning help-seeking, personal independence, strength, and control. The treatment and policy implications of these findings and recommendations for further research are discussed.

More is better: counseling participation and the effectiveness of outpatient drug treatment.

Counseling is a cornerstone of virtually all drug treatment modalities, yet there is relatively little research examining counseling effectiveness. This article addresses a simple question concerning counseling: Is more frequent participation in counseling associated with better treatment outcomes? Findings from an evaluation of the Los Angeles Target Cities Project indicate that monthly counseling frequency varied substantially for participants of outpatient programs, and more frequent counseling was associated with lower levels of relapse to drug use, even for individuals who successfully completed the treatment program. The association between counseling frequency and relapse did not attend to all types of counseling, however, but mainly to group and individual counseling. More frequent attendance of family counseling and 12-step meetings during the outpatient treatment phase did not significantly lower the probability of relapse. Frequent participants of group and individual counseling who continued to be frequent participants of 12-step meetings during the posttreatment period had the lowest probability of relapse. The policy implications of the findings and directions for further research are discussed.

Sexual abuse, physical abuse, and posttraumatic stress disorder among women participating in outpatient drug abuse treatment.

Findings from a prospective, longitudinal study of 182 women and 148 men in outpatient drug abuse treatment programs indicate that women are significantly more likely than men to experience sexual and physical abuse. Sexual and physical abuse are associated with higher levels of posttraumatic stress disorder (PTSD) symptomatology. Moreover, women are more likely than men to possess an array of psychological factors that predict relapse to drug use after treatment, including low self-esteem, depression, anxiety, and suicidal behavior, among others. But contrary to expectation, PTSD is not associated with relapse to drug use, nor are women more likely than men to relapse within a six-month posttreatment interval. Further analysis indicates that while women have more psychological risk factors associated with relapse, they are more likely than men to engage in the treatment process. Engagement in treatment, notably frequent participation in group counseling, appears to mitigate the higher risk of relapse for women.

Perceiving need for drug treatment: a look at eight hypotheses.

Data from the Drug Use Forecasting Program, sponsored by the National Institute of Justice, were used to examine eight hypotheses predicting the perceived need for drug treatment among drug-using arrestees. The findings support five of the eight hypotheses, including those related to drug severity, drug type, prior treatment experience, ethnicity, and the fear of AIDS. There was no support for the gender-related help-seeking or the social isolation hypotheses, and the findings contradict the maturing out hypothesis. The policy implications of our findings are discussed.