Progress

in the

Development

of CostEffective

Treatment

for

Drug Abusers

U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • Public Health Service • Alcohol, Drug Abuse, and Mental Health Administration
Progress in the Development of

Cost-Effective Treatment for

Drug Abusers

Editor:

Rebecca S. Ashery, D.S.W.

Division of Clinical Research

National Institute on Drug Abuse

NIDA Research Monograph 58

1985

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, Maryland
NIDA Research Monographs are prepared by the research divisions of the

National Institute on Drug Abuse and published by its Office of Science. The

primary objective of the series is to provide critical reviews of research problem

areas and techniques, the content of state of-the-art conferences, and integrative research reviews. Its dual publication emphasis is rapid and targeted dissemination to the scientific and professional community.

Editorial Advisors

Martin W. Adler, Ph.D.

Temple University School of Medicine

Philadelphia, Pennsylvania

Sydney Archer, Ph.D.

Rensselaer Polytechnic Institute

Troy, New York

Richard E. Belleville, Ph.D.

NB Associates. Health Sciences

Rockville, Maryland

Gilbert J. Botvin, Ph.D.

Cornell University Medical College

New York, New York

Joseph V. Brady, Ph.D.

The Johns Hopkins University School of Medicine

Baltimore, Maryland

Theodore J. Cicero, Ph.D.

Washington University School of Medicine

St Louis, Missouri

Sidney Cohen, M.D

Los Angeles, California

Reese T. Jones, M.D.

Langley Porter Neuropsychiatric Institute

San Francisco, California

Denise Kandel, Ph.D.

College of Physicians and Surgeons of Columbia University

New York, New York

Herbert Kleber, M.D.

Yale University School of Medicine

New Haven, Connecticut

NIDA Research Monograph Series

William Pollin, M.D.

DIRECTOR, NIDA

Jack Durell, M.D.

ASSOCIATE DIRECTOR FOR SCIENCE, NIDA

EDITOR-IN-CHIEF

Eleanor W. Waldrop

MANAGING EDITOR

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
Progress in the Development of

Cost-Effective Treatment for

Drug Abusers
ACKNOWLEDGMENT

This monograph is based upon papers presented at a technical

review which was held in Rockville, Maryland on June 7 and 8,

1984. The meeting was sponsored by the Division of Clinical

Research, National Institute on Drug Abuse.

COPYRIGHT STATUS

The National Institute on Drug Abuse has obtained permission from

the copyright holders to reproduce certain previously published

material as noted in the text. Further reproduction of this

material is prohibited without specific permission of the

copyright holders. All other material in this volume except

quoted passages from copyrighted sources is in the public domain

and may be used or reproduced without permission from the

Institute or the authors. Citation of the source is appreciated.

DHHS publication number (ADM)85-1401

Printed 1985

NIDA Research Monographs are indexed in the Index Medicus. They

are selectively included in the coverage of American Statistics

Index, BioSciences Information Service, Chemical Abstracts

Current Contents Psychological Abstracts, and Psychopharmacology

Abstracts.

iv
CONTENTS

Executive Summary...........................................

Jacqueline P. Ludford

Issues in the Brief Treatment of Drug Abusers..............

Rebecca Sager Ashery

Psychotherapy for Opiate Dependence . . . . . . . . . . . . . . . . . . . . . . . . . .

George E. Woody, Lester Luboreky, A. Thomas McLellan,

and Charles P. O’Brien

Behavior Therapy in Drug Abuse Treatment: Review

and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Maxine L. Stitzer, George E. Bigelow, and Mary E. McCaul

One-Person Family Therapy: A Modality of Brief Strategic

Family Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Franklin H. Foote, Jose Szapocanik, William M. Kurtinee,

Angel Perez-Vidal, and Olga K. Hervis

Personalized Nursing: An Effective Intervention Model for

Use with Drug-Dependent Women in an Emergency Room...........

Marcia D. Andersen

Brief Effective Treatment Strategies: Pharmacological

Therapy for Opiate Addicts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Herbert D. Kleber

Medical Maintenance Feasibility Study.......................

Don C. Des Jarlais, Herman Joseph, Vincent P. Dole,

and Marie E. Nyswander

The Role of Employment in the Rehabilitation of

Heroin Addicts ........................................

Jerome J. Platt and David Metager

vii

1

9

31

51

67

83

101

111

v
Who Is Serving Drug Abuse Clients: Treatment Delivery by

Professionals Versus Paraprofessionals, by Paid Staff

Versus Volunteers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

Leona S. Aiken, Leonard Losciuto, and Mary Ausetts

The Harvard Group Aftercare Program: Preliminary

Evaluation Results and Implementation Issues................. 147

William E. McAuliffe, James M.N. Ch'ien, Elaine Launer,

Rob Friedman, and Barry Feldman

Project Skills: Preliminary Results from a Theoretically

Based Aftercare Experiment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Richard F. Catalano and J. David Hawkins

List of NIDA Research Monographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

vi
EXECUTIVE SUMMARY

Jacqueline P. Ludford

A technical review meeting was convened by the National Institute

on Drug Abuse on June 7-8, 1984, to:

examine findings from studies of brief drug treatment interventions; and

based on what has been learned, consider the future

directions of such research.

In recent years, considerable progress has been made in assessing

the effectiveness of treatment modalities. Studies have shown

that drug abusers have a wide range of problems and needs, and

that a variety of treatment approaches are required. Numerous

factors have been found to be associated with treatment outcomes,

including psychopathology (especially depression and antisocial

personality disorders), physical health status, cultural factors,

family relationships, social networks and community supports,

employment status, vocational preparedness, and past criminality.

Existing treatment modalities (e.g., methadone maintenance, therapeutic communities, and outpatient drug free) have proven to be

effective in treating drug abusers, but they are limited in many

respects. For example, therapeutic communities have been particularly successful with clients sufficiently motivated to commit

themselves to stay in a residential environment for 6 months or

more, but a high percentage drop out before completing 3 months in

residence. Researchers have found that methadone programs are

less successful in treating clients who have psychiatric disorders

and clients who use alcohol excessively. Many women, particularly

those with dependent children, are not able to make the commitment

to a long-term rehabilitation process. Thus, it is not surprising

that existing (long-term) programs are failing to engage large

numbers of drug abusers. Studies of people treated in hospital

emergency rooms for drug-related episodes show that fewer than 12

percent are enrolled in treatment. Of those persons enrolled in

vii
short-term detoxification, only about 12 percent are successfully

recruited into longer term treatment from detoxification.

Despite a growing recognition of the need for alternative treatment methods that are cost effective, the basic drug treatment

system has not changed fundamentally over the past 10 years. Some

therapeutic communities have been experimenting with short-term

residential treatment followed by aftercare. Methadone programs

have also been testing methods of tapering or detoxifying clients

who are highly motivated to pursue a drug-free lifestyle.

This technical review brought together researchers who have

successfully conducted controlled studies of promising brief

therapies for different types of drug abusers. It provided them

an opportunity to present their findings and consider the implications for future research in this area.

In the first presentation, Ashery provided the rationale for the

review of research on brief therapies, She pointed out that there

is increasing pressure on agencies to use brief treatment methods

as programs become more effective in diagnosing and individualizing client needs and make efforts to become more cost efficient.

She highlighted the importance of diagnostics, client matching,

strategies, treatment specificity, and cost-effectiveness in

enhancing the treatment repertoire in the drug field.

Woody discussed findings from a study on the efficacy of shortterm psychotherapy for opiate dependence. The brief treatments

included drug counseling alone, drug counseling plus supportive

expressive psychotherapy, and drug counseling plus cognitive

behavioral psychotherapy. The results suggest that brief supplemental psychotherapy can make a significant difference in outcomes

for high severity (seriously depressed) methadone maintenance

clients.

Stitzer reviewed four operant-based behavior therapies for use in

drug abuse treatment: extinction, satiation, punishment, and

reinforcement. Among her findings, effectiveness of contingent

reinforcement and punishment intervention has been impressive in

the short-term studies conducted to date. Findings suggest that

contingency management procedures involving methadone dose delivery may be a clinically useful adjunct in methadone treatment.

Outcomes from a study of short-term family therapy approaches were

presented by Foote. Positive changes occurred in both One-Person

Family Therapy (OPFT) and Conjoint Family Therapy (CFT) groups in

reducing drug use and psychopathology, and in strengthening family

structure. The successful use of CPFT is especially significant,

since it is difficult to recruit whole families into treatment.

Andersen described a study which evaluated the effectiveness of a

nursing intervention model known as Personalized Nursing. This

model was designed to reach treatment-resistant drug-dependent

viii
women through emergency room contacts--those women who refused

referral to traditional drug treatment programs were provided

personalized nursing home visits on a regular basis, with a view

to reducing drug involvement. Findings indicated that nurses

were able to make some impact on the lives of women addicts,

although most differences between the experimental and control

groups disappeared in the 6-month followup.

The feasibility of applying pharmacologic adjuncts to narcotic

addicts who have psychiatric problems was examined by Kleber. He

presented evidence for the existence of a high prevalence of

psychiatric disorders in addicts, which could be treatable by

psychotropic medication. He identified some drugs which may be

of therapeutic use in treating such disorders.

Des Jarlais described the progress and preliminary findings from

a study designed to evaluate a medical maintenance approach. The

project being evaluated provides methadone maintenance treatment

for compliant, employed clients in a physician's office. Methadone is administered in the physician's office, in a manner

similar to chemotherapy for other chronic illnesses.

Platt examined the role of work as it relates to the rehabilitation of heroin addicts. One of the aims of this study is to

examine and determine different classes of variables relating to

employment. A second aim is to teach a process for overcoming

vocational problems and to evaluate the effectiveness of the

Vocational Problem-Solving Skills Training Project. In this

project, participants are involved in a process of selfexamination regarding their feelings, attitudes, and motivations

toward work.

Findings from two separate studies were presented by Aiken. One

study involved paraprofessionals; the other involved volunteers.

In a national study of paraprofessionals, there was little evidence that clients were selectively assigned to particular

counselor groups of professionals with degrees, ex-addict paraprofessionals without degrees, and paraprofessionals without

degrees with no addiction background. The Volunteer Utilization

Study distinguished among three groups of volunteers: 1) specialized professionals such as physicians, psychiatrists, and lawyers;

2) counselors; and 3) noncounseling personnel, including administrative support staff. Different types of counselors were

contrasted in terms of their functions and activities, attitudes

toward clients, attitudes of clients toward them, and progress of

their clients in treatment.

McAuliffe described the results from a 4-year cross-cultural study

(United States and Hong Kong) which evaluated an aftercare program

ix
for successfully treated opiate addicts. The program combines

both professionally led and self-help approaches. The study

posited that participation in an aftercare program could prevent

relapse and antisocial behavior while facilitating social

reintegration, which was validated by their research. The experimental groups had higher percentages with positive outcomes

(either entirely abstinent or having only rare "slips" for the

entire 12-month period).

Catalano reported on a study of Project Skills, an aftercare

program for reentry clients within 3 months of graduation from

residential treatment. The project was designed to teach clients

social skills to carry out daily living tasks at home and at work.

In addition, each client was paired with a community volunteer for

the purpose of joining and participating in a community organization. The investigators examined specific points where the

experimental intervention appears to be affecting intervening

variables and where it is not.

In the discussion that followed, the technical review participants

agreed that research on brief, effective strategies should proceed

on two tracks: 1) to test and evaluate methods and approaches

that hold promise of improving traditional modalities in the drug

field; and 2) to test and evaluate cost-effective methods of

reaching and treating drug abusers who have not been successfully

treated in traditional programs.

Based on the papers presented, the participants agreed that:

Sophistication in treatment research requires continued development of diagnostic instruments to help

clinicians and researchers develop individualized

treatments. Diagnostic tools can also make it

possible to develop client typologies and facilitate

client/program matching.

Whenever possible, treatment research studies should

include cost-effectiveness study components.

There are difficulties in conducting controlled

studies and problems in working with a drug-abusing

population. Participants suggested a NIDA-sponsored

meeting to discuss these issues.

More research must be focused on both adjunct and

primary pharmacological therapies to treat drug

abusers.

Strategies to disseminate research findings should

be given particular attention.

x
AUTHOR

Jacqueline P. Ludford, M.S.

Chief, Research Analysis Branch

Office of Science

National Institute on Drug Abuse

Rockville, MD 20857

xi

ISSUES IN THE BRIEF TREATMENT

OF DRUG ABUSERS

Rebecca Sager Ashery

There is no "quick fix" treatment for drug abusers. Administrators and clinicians alike will readily admit that drug abusers

are one of the most difficult client populations to treat: their

problems tend to be multidimensional. Such clients are likely to

have several relapses and remissions before reaching a permanently

drug-free state. Most drug abusers have a "drug lifestyle" and

continue to be influenced by friends, neighbors, and others in the

same lifestyle.

For these reasons, most traditional drug treatment programs were

designed to hold clients in treatment for a considerable period of

time. In the past, traditional therapeutic communities structured

their programs in a series of treatment phases requiring up to 2

years of residential care and ongoing support or aftercare after

graduation. Researchers have shown that those clients who stay in

treatment longer do better (De Leon 1984).

Methadone maintenance, the most widely used modality in the treatment of heroin addicts, tends to hold clients in treatment even

longer than traditional therapeutic communities. One can find

clients in some clinics who have been receiving methadone for 5 to

10 years while they continue to receive counseling and basic

medical services. Studies indicate that some clients who are

detoxified after being stabilized on methadone for some time tend

to relapse, although others do well (Dole and Joseph 1978). While

some researchers conclude that treatment must be continued indefinitely, others have found that methadone clients who are rehabilitated can be successfully detoxified and achieve long-term

abstinence (Stimnel 1978).

Outpatient drug-free modalities vary considerably in the amount of

time they want a client to be in treatment. Some provide longterm psychotherapy, but the vast majority offer basic individual

counseling as the primary treatment service. Counseling services

can be scheduled for three months to several years, depending on

1
the types of problems clients typically present, the types of

counselors (training and experience), and the resources available.

Drug-use patterns, as well as problems presented by clients, have

also been changing. Today, clients referred to drug programs are

more likely than in the past to be multiple drug users. In fact,

studies show that a high percentage of methadone clients use other

drugs while they are stabilized on methadone (Hunt et al. 1983).

BRIEF TREATMENT STRATEGIES

During the past several years, treatment resources have been

squeezed, and there is increasing pressure on programs to find

ways of using available resources more efficiently. Many therapeutic communities (TCs) are experimenting with short-term treatment protocols for some of their clients. Some TCs are being

structured to provide short-term (6 months or fewer) residential

care followed by a more basic aftercare program.

Inpatient psychiatric and hospital facilities tend to be too

expensive to maintain drug clients in treatment over long periods

of time. As a result, most of these inpatient programs have

established referral networks. After a brief intensive inpatient

phase, in which problems and needs are diagnosed, clients are

generally referred to residential or outpatient facilities.

Because of the changes that have been taking place in the drug

field and our present state of knowledge regarding treatment,

there has been a growing interest in brief, effective therapies.

"Brief" is defined as treatment for a time-limited short duration,

generally a maximum of 6 months.

While evidence exists that a certain minimum length of stay in

treatment may be necessary for some clients (Simpson 1979),

researchers have not established an optimum length of treatment.

Moreover, one may argue that both the client's interest and

society's interest may be served by developing therapies that

produce the desired changes in the client's functioning in the

shortest possible period. While brief, effective therapy may be

viewed either as an intervention in its own right or as part of a

longer-lasting program of treatment, there is an immediate payoff

in 1) improved client functioning and reduced social cost,

2) enhanced potential for engaging the client in a program of

rehabilitation, and 3) an opportunity to clarify and understand

the dynamics of specific treatment interventions with specific

client types. Moreover, given the increasing pressures on treatment agencies to use resources more efficiently and effectively,

development of brief, effective therapies has potential for more

rational organization of treatment systems.

2
ISSUES IN BRIEF TREATMENT

Four interrelated issues that both clinicians and researchers need

to address in the development of brief therapies are discussed

briefly below: 1) the task of developing diagnostic instruments

that can be used to pinpoint client problems/needs, yet are easy

to administer by workers in the drug field, 2) the matching of

clients to specific treatment protocols based on diagnostic

assessment, 3) the development of brief treatment strategies

either separate from or adjunct to current treatment modalities,

and 4) the measurement of the cost-effectiveness of treatment.

Diagnostics

Jaffe (1984) has noted that improvements in diagnostic measures

and sophistication of analytical techniques mark a major advance

in the drug abuse field. Through the testing, standardization,

and utilization of diagnostic tools, investigators and clinicians

are able to identify subgroups of clients with different treatment

needs. Woody and his colleagues (1984) have found that it is

important to identify patients suffering from severe depression

because they require special treatment. Instruments such as the

Addiction Severity Index (ASI) enable programs to obtain better

definitions and descriptions of patient subtypes (McLellan et al.

1980, Kosten et al. 1983). An instrument such as this can easily

be administered and scored by a technician and has wide appeal for

clinicians and researchers. Other investigators (Rounsaville et

al. 1980, Kosten et al. 1982, Rounsaville et al, 1982) have

reported findings on extensive testing and diagnostic work on

samples of opiate addicts. A variety of psychopathology was

found, including, most notably, depression, anxiety disorders,

alcoholism, and personality disorders.

Client/Treatment Matching

The development of brief therapies must include not only adequate

diagnostic screening and assessment but also client/treatment

matching to ensure that treatment protocols are appropriate to

client needs. Clinical researchers such as Woody et al. (1984)

have noted that different outcomes may be obtained, depending on

psychopathology. The "matching" of client to treatment is an

important step forward in reducing "treatment failures" and

budgetary waste.

Better matching between client type and treatment protocol can

result in great improvement, whereas the wrong combination can

result in no improvement at great cost to the client, the treatment facilities. and society. A controlled studv (McLellan et al.

1983) showed the benefits of matching alcohol-and drug-dependent

clients to specific treatments. Results indicated superior

performance during treatment and an average of 19 percent better

(6-month) outcomes for matched clients than for unmatched clients.

Woody (1984) is continuing to study psychiatric severity and

3
treatment matching in a controlled study, in which methadone

maintenance clients who have severe psychiatric symptoms will be

randomly assigned to psychotherapy or regular drug counseling.

Treatment Specificity

The components of treatment and the elements involved in the

treatment process were not well defined in earlier studies. For

example, in the Drug Abuse Reporting Program (DARP) studies

(Simpson 1982), "counseling" was not precisely defined, and the

various services received within modalities were not specified.

The DARP studies provided "gross" data to show that prevailing

drug treatment modalities are effective in treating drug abusers.

However, given the current status of the drug field, it is not

enough to know that treatment "works." There is a need to know

what kind of treatment works and for whom.

In the mid- and late '7Os, many "innovative" treatment strategies

were tested and developed. The focus on specific treatment

strategies was particularly in evidence at the National Drug Abuse

Conference in 1978, where papers were presented on a variety of

treatment strategies. Some of these approaches, which had long

been part of the health and mental health treatment repertoire,

were just finding their way into the drug abuse field. New treatment strategies included cognitive behavioral therapy, biofeedback, family therapy, hypnosis, and aftercare.

Efforts to demonstrate the effectiveness of particular interventions have included assessment of psychotherapy (Woody et al.

1983, Rounsaville et al. 1983, O'Brien et al. 1984), job-seeking

skills (Hall 1977, 1981a, 1981b), and monitoring the urine of

methadone clients (Havassy and Hall 1981), as well as use of

pharmacological agents (other than methadone) in treatment

programs (Kleber this volume). Woody et al. (1983) observed that

methadone clients with "high psychiairic severity" impairment

appeared to benefit from psychotherapy, while those with less

severe psychopathology did not; Rounsaville et al. (1983) found no

significant differences in treatment outcome when psychotherapy

was added to methadone maintenance. Hall (1981a, 1981b, 1984)

reported dramatically better rates of employment after clients'

participation in a job seekers' workshop, in comparison to control

subjects. Havassy and Hall (1981) found urine monitoring to be

ineffective in preventing chipping among methadone patients.

McAuliffe (this volume) found that the experimental group of

subjects who participated in an aftercare program of recovery

training and self-help had significantly better outcomes than a

control group who did not participate in such a program.

Cost-Effectiveness

Cost-effectiveness measures must be implemented as part of the

evaluation of brief treatment programs. Unfortunately, most

researchers have not incorporated cost-effectiveness measures into

4
their studies. There is a need to test and evaluate costeffective methods of reaching and treating drug abusers who have

not been successfully treated in traditional programs. Andersen

(this volume) evaluated a cost-efficient method of reaching women

heroin addicts in the emergency room who had rejected traditional

drug treatment modalities. Measuring cost-effectiveness means

examining not just the program itself, but the overall staffing

patterns, the allocation of resources, the appropriateness of

treatment for particular clients, the length of time in treatment,

and intensity of the treatment required. It may be less costly to

use a clinical psychologist half-time than to use a fulltime

untrained counselor. In addition, both researchers and program

administrators must also consider the costs to the program and to

the community of not implementing a particular treatment.

SUMMARY

In the chapters that follow, brief, effective treatment strategies

are presented by the authors. Each of these strategies has been

or is in the process of being tested and evaluated in practice.

These studies have been conducted by researchers throughout the

country. Almost all of them are controlled studies and represent

the first group of drug studies to evaluate brief treatments,

Some of these strategies are ready for dissemination to the field,

and others continue to be tested and refined. All have the

potential to enhance the treatment repertoire in the drug field.

Studies that have been completed have demonstrated that brief

treatment can be effective.

As a result of this research, a number of effective time-limited

treatment approaches and models are now available to the field.

For some of the treatments presented, the next level of research

sophistication--diagnosing and matching clients with particular

treatment protocols--has begun. Future research should focus not

only on the further development of specific brief treatments but

also on appropriate diagnosis of client problems and needs in

order to facilitate appropriate client/treatment matching, In the

future, special efforts should be made to demonstrate and evaluate

cost-effectiveness for implementation by treatment programs.

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Woody, G.; Psychotherapy for Opiate Addiction. National Institute

on Drug Abuse. Grant No. 1R01 DA03679-01. 1984

Woody, G.; McLellan, A.T., Luborsky, L.; O'Brien, C.; Blaine, J.;

Fox, S.; Herman, I.; and Beck, A. Severity of psychiatric

symptoms as a predictor of benefits from psychotherapy: The

Veterans Administration-Penn Study. Am J Psychiatry,

141(10):1172-1177, 1984.

Woody, G.; Luborsky, L.; McLellan, A.T.; O'Brien, C.P.; Beck,

A.T.; Blaine, J.; Herman, I.; and Hole, A. Psychotherapy for

opiate addicts - Does it help? Arch Gen Psychiatry, 40:639-645,

1983.

AUTHOR

Rebecca Sager Ashery, D.S.W.

Public Health Analyst

Treatment Research Branch

Division of Clinical Research

National Institute on Drug Abuse

Parklawn Building, Room lOA30

5600 Fishers Lane

Rockville, MD 20857

7

PSYCHOTHERAPY FOR

OPIATE DEPENDENCE

George E. Woody, Lester Luborsky,

A. Thomas McLellan, Charles P. O’Brien

INTRODUCTION

There are only two major studies evaluating the efficacy of

psychotherapy for opiate dependence. However, there are a number

of smaller studies, and there is an extensive literature on

psychiatric aspects of opiate dependence. A literature review is

a good starting point for a more detailed presentation of the

studies. The literature divides into four chronological periods.

First, there were case reports describing psychodynamic factors

associated with addiction. The authors of these reports were

psychoanalysts who emphasized the predominance of oral-dependent

character traits and the extreme difficulties encountered in

trying to treat addicts with psychotherapy. Fenichel (1945), Rado

(1933), Glover (1932), and Savitt (1963) represent this era.

The second period was immediately prior to the development of

methadone maintenance treatment programs. It was exemplified by

the 1958 study of Nyswander et al. This study advertised professional psychotherapy as being available to any interested addicts

in New York City. Only 70 persons responded by contacting the

clinic; only 13 of them became regularly engaged in therapy.

These engaged patients had an average of 35 appointments with

psychotherapists over a period of approximately 1 year. They were

compared with a control group of 22 minimally treated patients who

kept an average of eight appointments. Although the engaged

patients showed more benefits than the minimally treated patients,

the investigators concluded that psychotherapy's role was minimal

because so few applied for it, and only a small proportion of

those who applied actually became engaged. The earlier case

reports, in conjunction with Nyswander's more ambitious project,

seem to have influenced the way many clinicians and researchers

conceived of psychotherapy's role in addiction treatment. These

experiences appear to have stimulated efforts to look elsewhere

for effective treatments.

9
The third period began with the development of methadone maintenance programs, and coincided roughly with the application of

ego psychology to psychoanalytic work. This era was marked by a

rapid expansion of drug treatment programs. It saw the emergence

of many ideas and debates about how best to treat addicts within

this newly developed and greatly expanded treatment network. It

was marked by the involvement of many "helpers" with opiate

addicts. They ranged from highly trained medical professionals

such as psychiatrists and psychiatric nurses, to social workers to

paraprofessionals, including minimally trained mental health

workers and ex-addict counselors. During this period, the possible contribution of psychopathology to addiction, and the positive

influence that professional psychotherapy might contribute to outcome were reconsidered. The importance of psychiatric factors and

the possible role of psychotherapy were best described by Wurmser

(1979) and Khantzian et al. (1974). Both these writers are

psychiatrists with psychoanalytic training, and each spent considerable time treating opiate addicts, with many of their patients

being on methadone. Prominent among questions that Wurmser,

Khantzian, and others raised were: Do treatment programs work?

Does counseling add anything to methadone maintenance alone? Do

trained professionals add anything to the counseling given by less

trained, lower paid paraprofessionals?

During this period, a number of clinical studies and case reports

reexamined the efficacy of psychotherapy. Seven of these studies

employed random assignment; five of these seven showed that patients receiving professional psychotherapy did better than those

receiving counseling alone (Willett 1973, LaRosa et al. 1974,

Abrams 1979, Connett 1980, Resnick et al. 1981, Stanton et al.

1982, Rounsaville et al. 1983). Each study, except that conducted

by Stanton et al., had serious methodological problems. Among

these problems were small sample sizes, lack of definition of the

psychopathology being treated, lack of definition of the treatments provided, and use of a very narrow range of outcome

measures.

Stanton et al.'s study examined the efficacy of structural family

therapy when added to routine counseling services. The specific

treatment methods used were well described, several control groups

were employed, and a moderately broad range of outcome measures

was used. This study found good evidence for the efficacy of

structural family therapy with this population. It was also the

first well-designed study of a psychological treatment for methadone maintenance patients.

Though Stanton et al.'s study explored the efficacy of one

specific type of therapy, it did not study the types of psychopathology found in opiate addicts, nor did it examine the efficacy

of individual psychotherapy. These questions were addressed

during the fourth and most recent period by three major studies

which, taken together, are by far the best designed, most expensive, and most comprehensive ever to examine psychiatric aspects

10
of opiate dependence (Khantzian and Treece 1982, Rounsaville et

al. 1982, Woody et al. 1983). Each study had a diagnostic section, and two of the three (Rounsaville et al. 1982, Woody et al.

1983) studied the outcome of one or more individual psychotherapies with methadone maintenance addicts. The diagnostic

studies provided consistent results. Each found high levels of

psychopathology. The most common problem seen was depression,

especially major depressive disorder. Other common but less frequent problems were antisocial personality disorder, alcoholism,

and anxiety disorders. A smaller proportion of patients had mood

disorders such as hypomania or bipolar II, miscellaneous personality disorders, and schizophrenia (Rounsaville et al. 1982).

The two psychotherapy studies had differing results. The study

completed by Rounsaville et al. (1982) at the New Haven/Yale

program examined interpersonal psychotherapy (IPT) when added to

routine counseling and group therapy services in a methadone

treatment program. No differences in outcome were found between

the two groups, though both showed improvement (Rounsaville et al,

1983). Woody et al.'s study at the University of Pennsylvania and

Veterans Administration Medical Center, Philadelphia (1983), also

found that all treatment groups improved, but the patients who

received psychotherapy made more gains than the control group. A

related project was a clinical report, published in 1983 by

Herrington et al., which examined the progress and outcome of 40

physicians enrolled in an alcohol and drug dependence treatment

program in Wisconsin. This report was not a prospective study.

It did not employ random assignment or a control group, but it did

obtain followup on a reasonably large number of subjects for an

extended time (27 subjects were followed for 1 to 2 or more

years), and it carefully documented and described the various

aspects of the treatment program. The authors concluded several

factors were important for recovery. First was consistent participation in the overall program, a P-year, three-phase program

that started with inpatient detoxification and then moved into

outpatient and reentry activities. Also included were regular

urine testing, prompt return to meaningful employment, family

involvement in the patient's treatment, and psychotherapy. This

report was very positive in its evaluation of psychotherapy. It

concluded:

Insight oriented and expressive supportive psychotherapy effectively augments and enhances the other

elements of treatment. Although initially resistant to

psychotherapy, many of our patients later acknowledged

it to be one of the most significant events in their

recovery process (Herrington et al. 1982).

Woody et al. (1983) found similarly positive results. A detailed

examination of these results provides interesting data about how

psychotherapy might work, and for whom among this population it

11
might be most effective. These more detailed analyses were possible because the study employed a wide range of outcome measures

and examined a large number of subjects.

The treatments studied were drug counseling alone (DC), drug

counseling plus supportive expressive psychotherapy (SE), and drug

counseling plus cognitive behavioral psychotherapy (CB). The

major purpose was to see if there is any evidence that professional psychotherapy adds anything to routine counseling services.

Drug counseling was defined as a treatment delivered by paraprofessionals that focuses on identifying specific needs and

delivering concrete services. Examples of such services are:

monitoring progress, implementing program rules, intervening in

acute crisis situations, maintaining proper records, referring

patients to job training programs, screening patients for emergency psychiatric and medical problems, and discussing specific

problematic issues in current life situations.

The psychotherapies, in contrast, focused on identifying and

altering intrapsychic processes. Supportive expressive psychotherapy is an analytically oriented, focal psychotherapy that is

modeled after that described by Malan (1963) and Sifneos (1972).

and after a form of therapy used for many years at the Menninger

foundation in Topeka, Kansas (Wallerstein et al. 1956). The two

main techniques are supportive and expressive, as the name

implies. The expressive ones aim to help patients identify and

work through problematic relationship themes. Special attention

is paid to the meanings that patients attach to drug dependence.

Cognitive behavioral psychotherapy is an active, directive, timelimited system of psychotherapy that focuses on uncovering and

understanding the relationship and influence of automatic thoughts

and underlying assumptions to problematic feelings and behaviors.

The therapy models that were developed by Aaron T. Beck, M.D.,

have been shown to be effective for treatment of certain types of

depression (Beck 1976). Beck and his colleagues have found that

depressed patients have subscribed to a system of negatively

biased thoughts, attitudes, and beliefs that lead to a consistently distorted perception of themselves, the future, and the

world around them. Beck has found that significant improvement in

mood can result when a person can learn systematically to correct

these exaggerated thoughts so that they more accurately reflect

reality.

Each of these treatments is described in a manual (Luhorsky 1976,

Beck and Emery 1977, and Woody et al. 1977). These manuals were

used for training and ongoing supervision of counselors and

therapists. The entire study took approximately 4 1/2 years to

complete. The psychotherapy was offered for 6 months. Patients

were evaluated at intake, 7 months (1 month after therapy ended),

and 1 year. Eighteen counselors and nine therapists participated.

There were five SE and four CB therapists. All therapists except

12
two had either an M.D. or a Ph.D. and at least 2 years of clinical

experience since completing training. One CB therapist had no

formal degree but had 7 years experience as a CB therapist. One

SE therapist was completing a Ph.D. program but had 3 years of

clinical experience during one portion of training. All therapists had some experience with addicts or alcoholics, and five had

worked in either alcohol or other drug abuse treatment programs

for 1 or more years. Care was taken to select only therapists who

were both experienced in their particular techniques and also

interested in treating drug addicts. The therapists were chosen

by the supervisor of each therapy --Dr. Luborsky for SE therapists

and Dr. Beck for CR therapists. Because there were more applicants than jobs, we could interview and then choose the therapists

judged best for this population. The drug counselors had worked

in the drug treatment program for an average of 3 years and were

familiar with counseling techniques and clinic procedures. About

half had bachelor's degrees, and most had learned counseling

procedures through on-the-job training. Some had also been

trained as corpsmen while on military duty.

Study Design

The design of the study was as follows: The project was fully

described to prospective patients, and those who were interested

were randomly assigned to one of the three treatment conditions

upon signing a consent form and completing an extensive intake

procedure. Patients were given a brief explanation of the kind of

treatment they would receive after random assignment, in the

manner described by Orne and Wender (1968). This explanation was

given on the assumption that most patients had little knowledge of

what was expected in psychotherapy and that a brief explanation

would facilitate the treatment process. Following this, the

principal investigator or a research staff member introduced the

patient to his therapist or counselor and encouraged him to keep

all scheduled appointments.

Patients who completed the intake procedure were required to

complete three appointments with their counselor and an additional

three appointments with their therapist (if they were assigned to

SE or CB. These initial appointments had to be completed within

the first 6 weeks; if they failed to complete the appointments

they were considered nonengaged and dropped from the study.

Approximately 80 percent of patients who completed intake kept

these initial appointments. The demographic status of the

patients in each of the treatment groups is shown in table 1;

table 2 summarizes their lifetime psychiatric diagnoses (based on

Research Diagnostic Criteria [RDC]); the measures used are shown

in table 3; and the design is outlined in figure 1.

13
TABLE 1. Background status of 110 male, opiate-dependent psychotherapy subjects

Treatment Group*

Characteristic (N=32) (N=39) (N=39)

Age (years) 31 + 6 29 + 6 29 + 5

Race (percent)

Black 59 67 59

White 41 33 41

Education (years) 12 13 12

Marital status (percent)

Married 37 36

Divorced, separated** 25

28

49 28

Never married 38 23 36

Living with parents 28 31 28

Living alone** 12 13 23

Criminal convictions (average) 4 3 3

Months incarcerated (average) 13 14 11

Years problem drinking (average) 1 2 2

Years regular drug use (average)

Heroin** 7 10 11

Methadone hydrochloride 2 2 2

Depressants 2 2 2

Stimulants 2 1 1

Prior drug treatments 4 3 4

*SE indicates supportive-expressive therapy; CB, cognitivebehavioral therapy; and DC, drug counseling.

**P < .O1 by analysis of variance and paired t test.

14
TABLE 2. Lifetime research diagnostic criteria diagnoses

Treatment Group*

Number (Percent)

Diagnosis SE CB DC Total

Drug use disorder

Affective disorders

Major depressive disorder

Minor depressive disorder**

Intermittent depressive disorder

Labile personality

Cyclothymic personality

Hypomanic disorder***

Manic disorder

Bipolar II

Anxiety disorders

Generalized anxiety

Panic disorder

Phobic disorder

Obsessive-compulsive disorder

Alcoholism

Antisocial personality

Schizotypal features

Other psychiatric disorders

32 (100)

13 (41)

0 (0)

7 (22)

2 (6)

5 (16)

7 (23)

0 (0)

4 (13)

1 (3)

0 (0)

3 (9)

1 (3)

7 (22)

6 (19)

2 (6)

1 (3)

39 (100) 39 (100)

14 (36) 20 (51)

1 (3) 7 (18)

3 17) 3 (7)

6 (15) 2 (5)

3 (8) 3 (8)

2 (5) 12 (30)

0 (0) 1 (3)

1 (3) 6 (15)

1 0) 1 (3)

0 (0) 0 (0)

0 (0) I (3)

0 (0) 1 (0)

9 (24) 1O (26)

6 (15) 4 (10)

1 (3) 3 (8)

0 (0) 0 (0)

110 (100)

47 (43)

8 (7)

13 (12)

10 (9)

11 (10)

21 (19)

1 (1)

11 (10)

3 (3)

0 (0)

4 (4)

2 (2)

26 (24)

16 (15)

6 (6)

1 (1)

*SE indicates supportive-expressive therapy; CB, cognitlve-behavioral therapy;

and DC, drug counseling.

**P < .05.

 ***P < .O1 by analysis of variance.

15
TABLE 3. Outcome measures administered, by month

Intake 1 Month 7 Month 12 Month

Consent form

Maudsley Personality Inventory

Beck Depression Inventory (BDI)

Social Adjustment Scale (Weissman)

Symptom Checklist-90 (SCL-90)

Shipley

Relationship inventory - counselor

RelationshIp inventory - therapist

Helping relationshlp - counselor

Helping relationship - theraplst

Patient termination form

Schedule of Affective Disorders &

Schizophrenia - Life Time Version (SADS-L)

Research Diagnostic Criteria

DSM III

Previous treatment form

Schedule for Affective Disorders -

Change Version (SADS-C)

Addiction Severity Index

Background data Interview

Social Information form

Followup form

Therapist facilitative behavior

Goals of therapy - therapist

Terminatlon form - therapist

Counselor facilitative behavior

Termination form - counselor

16
FIGURE 1. Study design
Results

The results have been published elsewhere (Woody et al. 1983) and

are summarized as follows: Sixty percent of patients meeting the

study criteria expressed an interest in participating; 40 percent

of these actually became engaged. One hundred and ten subjects

completed the study intake procedure, kept three or more appointments within the first 6 weeks of the project, and also completed

the 7-month evaluation.

We examined subgroups of the overall sample in an attempt to find

those subjects who benefited the most and the least from the additional treatments. Our rationale for the first series of these

examinations was as follows: Clinical observations suggest that

some proportion of drug-taking in almost all addicts is an attempt

to self-medicate discomfort associated with life stress or psychiatric symptoms. However, there is reason to believe that this

attempt at self-medication may account for a much greater proportion of drug-taking in those addicts with clinically significant

levels of psychiatric symptoms. This, in turn, suggests that although the addition of professional psychotherapy may be generally

useful in drug abuse treatments, it may be particularly important

for that group of patients with additional serious psychiatric

illness. Further, because psychotherapy services are usually

expensive and of limited availability, it is important from a

practical perspective to identify subgroups of the patient population who could be most responsive to additional psychotherapy.

We therefore used the pretreatment ASI psychiatric severity rating

at the start of the study as well as the pretreatment scores on

the BDI, the Maudsley Neuroticism Scale, the total scores on the

SADS-C and the SCL-90, and the General Assessment Scale of the

SADS-L to evaluate the patient's baseline psychiatric status. We

combined these scores into a single composite that was highly

correlated with the individual measures and generally indicative

of the patients' global psychiatric status. Patients were divided

into thirds according to their global psychiatric status rating.

The third with the lowest scores were termed low-severity (LOW);

the middle third, mid-severity (MID); the most disturbed, highseverity (HIGH) patients. Initial severity scores in all three

groups were comparable for each treatment condition.

An examination of the three low-severity groups indicated substantial improvement in several measures in all treatment conditions.

There was some indication that the SE-LOW and DC-LOW patients had

more improvement and better outcome than the CB-LOW patients in

employment, but the paired analyses on the 7-month outcome measures indicated no significant differences (p > .lO) across the

three treatments.

Mid-severity patients showed substantial positive change in all

three treatment conditions, although the psychotherapy groups

showed more changes in the psychological test measures. However,

18
unlike the LOW patients, the 7-month comparisons (ANCOVA) indicated significant between-groups differences in 10 of the 16

comparisons, with the DC group showing the worst outcome on 7.

Thus, while all groups showed a number of significant improvements, the psychotherapy groups showed generally better outcomes

for these MID patients.

The three HIGH groups showed very different results. The HIGH

patients from both SE and CB therapy groups showed a number of

significant improvements in most of the outcome measures,

especially in employment, legal, and psychiatric status. In

contrast, the HIGH patients in the counseling group (DC) showed

very little improvement generally and significant change (P < .05)

only in the drug-use measures. Comparisons of the adjusted

(ANCOVA) 7-month scores indicated that the DC-HIGH oatients had

significantly poorer outcomes (p=<.O5 or less) on 9 of the 16

comparisons.

In addition to the 'I-month data, we also examined the standard

clinical records of methadone dose, prescriptions for ancillary

psychotropic medications, and urinalysis reports for patients in

each of the treatment subgroups. These three measures are routinely and regularly collected on all patients during treatment.

We have found them sensitive indicators of treatment response.

Results of analyses of variance on these measures indicated significant differences among the severity groups on methadone dose

(F=10.4, df 2,71, p < .OO1) and prescriptions for psychotropic

medications (F=16.7, df 2,71, p < .OOl). HIGH patients, regardless of treatment condition, had higher mean doses of methadone, a

higher proportion of drug-positive urines, and a higher frequency

of psychotropic drug prescriptions (p=.05 or less) than LOW or MID

patients, who did not differ from each other (p > .lO). Comparisons across therapy conditions yielded significant main effects on

the variables of methadone dose (F=21.7. df 2.71. < .OOl) and

psychotropic medication prescriptions (F=13.3; df 2,71, p < .OO1).

Treatment-bv-severity interaction effects were significant for all

three variables (p < .01). There were no significant differences

in these variables among the three treatment conditions for the

LOW patients (p > .1O). However, as in the analyses of the ASI

data. comparisons for the MID and especiallv the HIGH oatients

yielded much different results. The MID and HIGH DC patients had

a sianificantlv hiaher mean methadone dose (p < .O1), a significantly higher proportion of drug-positive urines (p < 05); and a

significantly higher frequency of prescriptions for psychotropic

medications (p < .O1) than patients in either of the psychotherapy

groups in the HIGH range. The two psychotherapy groups did not

differ from each other on any measure (p > .1O).

Three main findings were evident from these results. First, and

not surprisingly, patients with high levels of psychiatric symptoms had less satisfactory pretreatment adjustment in all areas of

functioning than other patients. This finding is consistent with

19
earlier work done here and elsewhere (McLellan et al. 1983,

Luborsky et al. in press-a), and it applies regardless of treatment group assignment. Second, the HIGH patients did not respond

nearly as well to any of the treatments as did the MID or LOW

patients. Their response to counseling alone (DC) was especially

problematic.

Our third and the most novel finding was the relationship between

the patients' psychiatric severity and the specific treatments

that were used. The additional psychotherapy altered the typical

relationship between psychiatric severity and outcome. The HIGH

patients who received the additional therapy showed improvement in

many areas, while the HIGH DC group improved only in drug use.

Further, these HIGH therapy patients were able to make their gains

with lower doses of methadone, less prescribed psychotropic medication, and less illicit drug use than HIGH DC patients. A more

complete description of these results is available elsewhere

(Woody et al. in press).

We next examined outcome by therapist. We had formed the impression that some therapists consistently effected better outcomes

than others. This study offered a particularly good opportunity

to examine differences in therapist performance for three reasons.

First, the therapists were trained and regularly supervised using

manuals that explicitly defined and described the techniques employed in the performance of each therapy. These manuals provided

specific criteria that could be used by independent raters to derive reliable, valid, and discriminable evaluations of the nature

and content of the three therapies (Luborsky et al. 1982).

Second, each therapist's sessions were tape recorded throughout

the course of the study. These taped sessions provided a representative sample of each therapist's performance during therapy

and could be used by independent raters to evaluate the extent to

which the therapists conformed to the particular techniques of

their therapy as defined by the manuals. Finally, objective data

on several measures of patient status were collected at the start

of the study and again at 7-month followup. This provided a

comprehensive range of measures upon which to evaluate patient

improvement and outcome.

Our initial step in comparing the effectiveness of the therapists

was to calculate the mean percent change from the start of the

study to the 7-month evaluation point for all patients in each

therapist's caseload. This improvement rate was calculated on

seven outcome measures from the Addiction Severity Index (ASI).

Table 4 shows the percent change from pretreatment status

(positive or negative) for each therapist's caseload.

20
TABLE 4. Percent change from start of treatment to 7-month followup, by therapist

Percent Change by Outcome Measure*

Drug Employ. Legal Psychiatric Beck Maudsley Average

Number Use Status Status Status Dep. SCL-90 N Scale Effect-Size**

SE Therapists

A

B

C

10 34 32 20 102 58 44 64 .74

8 33 34 17 49 37 46 59 .59

8 -14 12 7 -4 8 -2 13 .19

CB Therapists

D 11 61 19 17 34 36 39 44 .53

E 10 70 22 13 19 24 30 30 .44

F 9 48 10 11 14 14 21 33 .46

DC Therapists

G

H

I

9 51 8 13 4 4 9 -1 .20

6 46 -4 6 2 -3 11 3 .13

7 66 17 7 15 14 15 17 .27

*All criteria were measured during the 30 days before treatment start and before 7-month followup. Factor

scores represent composites of several items indicative of patient status in that area. Percent change

was calculated against the treatment start baseline.

**Within-therapist effect-size was averaged across all seven criteria. Effect-size calculation for each

criterion was pretreatment mean minus posttreatment mean, divided by pretreatment standard deviation.

Small change = .2, moderate change = .5, large change = .8.
The differences in patient improvement rates among the therapists'

caseloads are obvious from table 4. This was true in all treatment groups and on most of the seven outcome measures. One-way

analyses of variance on the percent change scores indicated a

significant between-therapists effect (p < .05 or less) on all

measures. Further, the range in these performance measures was

quite dramatic. For example, the patients of therapist A showed

an average improvement in psychological status from the start to

the 7-month point of more than 100 percent, while therapist E's

patients showed only a 19 percent change, and therapist C's

patients showed 4 percent worsening.

As an additional measure of the magnitude of change shown by each

therapist's caseload, effect-size measures were calculated for

each of the seven change measures and then averaged to produce a

single score (table 4, last column). These effect-size measures

have limitations with regard to their generalizability but they do

offer an additional means of comparing therapist efficacy. As can

be seen, the average effect sizes for the nine therapists parallel

the data on percent change, with therapist A showing by far the

largest effect; therapists B,D,E,F showing moderate changes; and

therapist C, along with counselors G,H,I, showing the smallest

changes.

Thus, we found that the choice of therapist was an important

determinant of outcome. Further analyses of the therapist data

indicated that those who obtained the best results formed the most

positive relationships with their patients, and also conformed the

most closely to their specified techniques. Our impression is

that a positive, helping relationship provides a necessary foundation from which the psychological techniques can be usefully

applied. The absence of a Dositive relationship makes it verv

difficult for the techniques of the psychotherapy to be meaningfully applied. These results are described in greater detail in

another paper (Luborsky et al. in press-b).

We then analyzed outcome by diagnostic groupings. We compared

treatment outcome for psychotherapy patients who fell into three

RDC categories: opiate dependence only, opiate dependence and

depression, and opiate dependence and antisocial personality disorder (ASP). Both therapy groups were combined in this analysis

to achieve a sufficient number of subjects in each category.

Patients in each of the first two categories improved considerably, with the largest therapy effect being in those with depression. However, there was no significant effect of psychotherapy

in patients with only ASP, except that drug use was reduced.

These findings are supportive of the idea expressed by many others

that psychotherapy is not helpful for people with only sociopathy

(Shamsie 1981). These findings are summarized in table 5.

22
TABLE 5. Effectiveness of therapy on three diagnostic groups (RDC diagnoses)

Opiate Abuse Only Opiate Abuse and Depression Opiate Abuse and Anti-Social

Start Start Start

(N=28) 7-Month (N=14) 7-Month (N=lO) 7-Month

Drug use factor* 199** 106 189** 26 154*** 118

Days opiates 8*** 4 6 3 6

Days nonopiates 4 2 2 1 4

5

3

Employment 129** 48 148 86 133 129

Days working 9 13 4*** 8 6 7

Money earned 417*** 535 334 391 151 211

Legal status 217*** 121 209*** 109 255 186

Crime days 7*** 3 5*** 2 5 3

Illegal income 248*** 106 227*** 75 291 226

Psychiatric status

Beck

SADS depression

SADS anxiety

Maudsley N

SCL-90

GAS

Psychological severity

167*** 122 232** 109 189 159

10*** 6 15** 10 12 12

17 17 28 11 23 21

17 15 22 22 21 20

20 17 32** 20 25 23

138*** 123 165*** 151 160 155

66 75 47** 70 63 71

2.1 1.8 5.8*** 2.9 4.6 3.8

*All criteria measured drug 30 days prior to study start and at 7-month followup. Higher scores indicate

greater severity.

**p < .Ol.

***p < .05.
In a subsequent analysis we examined outcomes of patients with DSM

III diagnoses of opiate dependence and antisocial personality disorder only, and compared them with patients who had opiate dependence and antisocial personality plus an additional psychiatric

disorder. Here, the group of patients with another psychiatric

disorder showed significant gains, mainly in the psychiatric area.

Thus, some patients with sociopathy appear to be therapy-amenable,

and these are those with symptoms of other psychiatric disorders

such as depression or anxiety. However, the disabilities associated with the core characteristics of antisocial personality

disorder are much less amenable to change, even in this more responsive subgroup. These findings appear similar to those found

by Adams in a study of people with a DSM III diagnosis of ASP

(1961). These findings are also described in more detail in

another paper (Woody et al., in preparation).

We have done few detailed analyses on the 12-month data at this

time. The overall results, though, are similar to the 7-month

findings in showing better outcome for the psychotherapy groups.

This brief review could make the study sound easier than it actually was. We encountered many difficulties. Some of these were

anticipated during the planning stage. Before beginning the

study, we gave considerable thought to the administrative procedures that might be used in a psychotherapy study with this

population. We had participated in the family therapy study done

by Stanton et al. in 1976 (Stanton et al. 1982), and that experience taught us that there are special conditions under which therapy has the best chance to work. Based on that study, we expected

three problems to occur: 1) missed appointments by patients,

2) competition between counselors and therapists, and 3) morale

loss by therapists in response to the nature of the addicts'

problems.

We implemented the following procedures from the start of the

study, in a largely successful attempt to combat these problems:

1) The program director administered the psychotherapy

study as an integral part of the ongoing treatment

services.

2) The therapists had part-time offices in the treatment facility, and efforts were made to ensure that

they felt they were a part of the treatment

program. This close linkage between tne therapists

and the program reduced the chances that therapists

would feel disengaged, or that they would be

perceived as irrelevant by the patients.

3) Attention was paid to facilitating coordination and

cooperation between therapists and counselors,

especially at the beginning of the project.

24
4) Attention was paid to patient compliance. Patients

were reminded promptly if they missed appointments.

Missed appointments were considered reflections of

difficult social conditions or transference phenomena that should be addressed in therapy.

5) Patients were started in therapy shortly after they

entered the program because that probably increases

the chances for successful engagement.

6) Attention was paid to hiring only therapists who

were interested in drug addicts and who felt

comfortable with them.

7) Ongoing supervision of therapists was provided by a

senior clinician who was skilled in the particular

form of treatment that the therapist was to

perform.

In addition to these administrative procedures, therapists were

hired by time blocks so that they were paid whether patients kept

or missed appointments, and counselors were paid $2 per patient

for filling out weekly treatment report forms that were part of

the data collection process.

These methods were necessary to carry out this study, and their

absence in the New Haven/Yale project (Rounsaville et al. 1982)

might have accounted for the much lower participation and compliance of their patients in the psychotherapy program.

CONCLUSIONS

The practical applications of this work are very clear. Our data

indicate that the traditional poor outcome of high-severity methadone patients can be improved by the addition of competent and

interested professional psychotherapists to the ongoing treatment

services. These psychotherapists must be fully integrated into

the overall program, and must be able to get along with other

staff members. When therapists are integrated in this manner, we

find that the counselors look to them for help with their most

difficult patients. If therapy works, the successful management

of these troublesome high-severity patients can bring relief to

all staff, in addition to providing direct benefits to the individual patients. Cost-effectiveness arguments can be made on the

basis of the more positive results that can be achieved with a

group of patients who make very little progress with the standard

treatment, usually at considerable expenditure of staff time. We

saw some evidence for a reduction of time spent in hospital by the

high-severity patients who received additional therapy (Woody et

al. 1984).

Little mention has been made of group therapy in this paper. No

major studies have been done on group therapy with this

25
population. One of the small studies cited earlier used groups

and found evidence for positive results (LaRosa et al. 1974),

while another found no differences in outcome between group

therapy and counseling alone (Willett 1973). Group therapy is

widely used in residential programs. It appears to be used less

extensively in most outpatient programs. It has the potential to

be a more cost-effective way of delivering professional treatment

than individual therapy. Thus, our impression is that it can be

helpful.

However, we have encountered serious practical problems in trying

to establish it as a viable modality. Effective group therapy requires regular attendance by all members. Frequent absences seriously interfere with the group process and make meaningful therapy

very difficult. Unacceptable levels of attendance have been our

greatest problem in trying to start meaningful groups, and we have

found that individual therapy is much more easily adapted to

methadone patients. They are not good at keeping regular appointments to begin with, and they also are subject to a large number

of schedule changes, e.g. patients working shifts with periodic

schedule changes, and people who must appear in court or at social

agencies at frequent and unpredictable intervals. This combination of impaired self-discipline plus social circumstances has

contributed to our problems in carrying out group therapy.

There also may be an inordinately high level of resistance to

group therapy in this population. Almost all of our patients have

committed serious crimes. Effective therapy requires a high level

of disclosure, and the issues of confidentiality in a group setting are much more complicated than in individual therapy.

Patients cannot be certain who they are telling about their behavior in group therapy and what the group members may do with their

disclosures. This kind of problem may contribute to difficulties

in carrying out meaningful group therapy, especially in an outpatient program. Another problematic issue has been the tendency

of some groups to turn into either gripe sessions or efforts to

use group pressure to accomplish dubious goals such as, give out

travel money, prescribe tranquilizers, or provide more take-home

doses. This has been a problem with some of the large groups. It

is not nearly so serious a problem as poor attendance, but it can

create diversions and, when combined with irregular attendance, it

can be difficult to redirect into a therapeutic process. Thus,

while we are not opposed to group therapy and think it can work,

we think individual therapy has been much easier to implement.

Our major efforts have, therefore, been directed toward individual

therapy. We are pleased with the results. The observed outcomes

fit both with common sense and with our clinical experience. They

are of potential importance to the field and they could alter the

typical practices and staffing patterns of methadone programs. It

is important to see if they can be replicated in other programs,

using techniques similar to those described here.

26
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treatment program for opioid addicted persons: An adjunct to

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 Cognitive Therapy and the Emotional Disorders. New

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Connett, G. Comparison of progress of patients with professional

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an attempt to cope: Clinical observations. Am J Psychiatry

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LaRosa, J.C.; Lipsius, J.H.; and LaRosa, J.H. Experiences with a

combination of group therapy and methadone maintenance in the

treatment of heroin addiction. Int J Addict 9:605-617, 1974.

Luborsky, L. A general manual for supportive-expressive psychoanalytically oriented psychotherapy. Unpublished manuscript.

Philadelphia: University of Pennsylvania Hospital, 1976.

Luborsky, L.; Mintz, J.; Auerbach, A.; and Crits-Cristoph, P.

Psychotherapy: Who Will Benefit and How? New York: McGrawHill, in press-a.

Luborsky, L.; Woody, G.E.; McLellan, A.T.; and O'Brien, C.P. Can

independent judges recognize different psychotherapies? An

experience with-manual-guided therapies: J Consult Clin Psycho1

50(1):49-62, 1982.

Luborsky, L.; McLellan, A.T.; Woody, G.E.; O'Brien, C.P.; and

Auerbach, A. Therapist success and determinants. Arch Gen

Psychiatry, in press-b.

Malan, D. A Study of Brief Psychotherapy. Philadelphia: J.B.

Lippincott Co., 1963.

McLellan, A.T.; Luborsky, L.; Woody, G.E.; Druley, K.A.; and

O'Brien, C.P. Predicting response to alcohol and drug abuse

treatments: The role of psychiatric severity. Arch Gen

Psychiatry 40:620-625, 1983.

Nyswander, M.; Winick, C.; Bernstein, A.; et al. The treatment of

drug addicts as voluntary outpatients: A progress report. Am J

Orthopsychiatry 28:714-729, 1958.

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Orne, M., and Wender, P. Anticipatory socialization for psychotherapy: Method and rationale. Am J Psychiatry 124:88-98,

1968.

Rado, S. The psychoanalysis of pharmacothymia. Psychoanal Q 2:1-

23. 1933.

L.C., ed. Problems of Drug Dependence: 1980. National

Institute on Drug Abuse Research Monograph. DHHS Pub. No.

(ADM) 81-1058. Washington, D.C.: Supt. of DOCs., U.S. Govt.

Print. Off., 1981. pp. 109-115.

Rounsaville, R.J.; Glazer, W.; Wilber, C.H.; et a

interpersonal psychotherapy in methadone-maintained opiate

Resnick, R.R.; Washton, A.M.; Stone-Washton, N.; et al.

Psychotherapy and naltrexone in opioid dependence. In: Harris,

1 . Short-term

addicts. Arch Gen Psychiatry 40:629-636, 1983.

Rounsaville, B.J.;eissman, J.J.; Wilber, C.H. et al. The

heterogeneity of psychiatric diagnosis in treated opiate

addicts. Arch Gen Psychiatry 39:161-166, 1982.

Savitt, R.A. Psychoanalytic studies in addiction. Ego structure

in narcotic addiction. Psychoanal Q 32:42-57, 1963.

Shamsie, S.J. Antisocial adolescents: Our treatments do not

work--where do we go from here? Can J Psychiatry 26(5):357-64,

1981,

Sifneos P.

Cambridge:

Short-term Psychotherapy and Emotional Crisis.

Harvard University Press, 1972.

Stanton, M.D.; Todd, T.; et al (eds.). The Family Therapy of Drug

Abuse and Addiction. New York: Guilford Press, 1982.

Wallerstein R.; Robbins, L.; Sargent, H.; et al. The psychotherapy research project of the Menninger Foundation. Bull

Menninger Clin 20:221-280, 1956.

Willett, E.A. Group therapy in a methadone treatment program: An

evaluation of changes in interpersonal behavior. Int J Addict

8:33-39, 1973.

Woody, G.E.; O'Brien, C.P.; and McLellan, A.T. Treatments for

opiate dependence. Psychiatric Annals 14:4, 1984.

Woody, G.E.; Stockdale, D.; and Hargrove, E. A manual for drug

counseling. Unpublished manuscript. Philadelphia: Veterans

Administration Hospital, 1977.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P.

Sociopathy: A negative predictor of the benefits of

psychotherapy. In preparation.

Woody, G.E.; Luborsky, L.; McLellan, A.T.; O'Brien, C.P.; Beck,

A.T.; Rlaine, J.; Herman, I.; and Hole, A. Psychotherapy for

opiate addicts. Arch Gen Psychiatry 40:639-645, 1983.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; O'Brien, C.P.; Blaine,

J.; Fox, S.; Herman, I.; and Beck, A.T. Psychiatric severity as

a predictor of benefits from psychotherapy: The Penn VA study.

Am J Psychiatry 141(10):1172-1177, 1984.

Wurmser, L. The Hidden Dimension: Psychopathology of Compulsive

Drug Use. New York: Jason Aronson, 1979.

28
AUTHORS

George E. Woody, M.D.

Lester Luborsky, Ph.D.

A. Thomas McLellan, Ph.D.

Charles P. O'Brien, M.D., Ph.D.

Drug Dependency Treatment Unit

Philadelphia VA Medical Center

39th and Woodland

Philadelphia, PA 19104

and

Department of Psychiatry

University of Pennsylvania

Philadelphia, PA

29

BEHAVIOR THERAPY IN

DRUG ABUSE TREATMENT:

REVIEW AND EVALUATION

Maxine L. Stitzer,

George E. Bigelow, Mary E. McCaul

INTRODUCTION

This paper reviews operant-based behavior therapies that can be

used to promote improvement in drug abuse patients. Respondent

therapies such as relaxation training and biofeedback, which

attempt to change internal responses to stimuli, will not be

covered; their application in treatment of drug abuse has recently

been reviewed by Hall (1983), Klajner et al. (1984), and Stitzer

et al. (1983a). The paper describes a behavioral model of drug

abuse and then discusses four behavior therapy strategies that can

be used in treatment of drug abuse: extinction, satiation,

punishment, and reinforcement. Examples are given of behavior

therapy techniques that have been implemented in treatment of drug

abuse, particularly in the treatment of opiate abuse; studies

evaluating the efficacy of these techniques are reviewed and

recommendations are offered on applying behavior therapy interventions in drug abuse treatment settings.

BEHAVIORAL MODEL OF DRUG ABUSE

One of the things that we have come to understand about drug abuse

during the last 30 years is that drugs can act as powerful biological reinforcers in a manner analogous to such reinforcers as food

and sex. Evidence for this view comes from the animal laboratory,

where it has been clearly demonstrated that animals such as rats

and monkeys will work (i.e., press levers) to obtain infusions of

commonly abused drugs, including narcotics, sedatives, and stimulants (Deneau et al. 1969, Johanson and Schuster 1982). For these

laboratory animals, drugs act as reinforcers in the absence of

social deprivation, peer pressure, family histories of drug abuse,

31
or psychiatric illness, all of which have been cited as possible

necessary precursors of drug abuse in humans. Further, it is

clear from animal studies that drugs can act as reinforcers in the

absence of physical dependence (Kelleher and Goldberg 1975), which

suggests that the pleasurable or reinforcing properties of drugs

exist independently of the need to avoid unpleasant symptoms of

withdrawal. The fact that drugs can act as potent reinforcers to

maintain behavior implies that every human has the potential to

become a drug abuser. However, not everyone who tries drugs becomes an abuser, and there are vast individual differences in the

amount, type, and pattern of drug use in which people engage. The

factors that determine whether a particular individual will become

a drug abuser are as yet poorly understood, although they certainly include such things as availability of drugs and the behavior

and attitudes of friends and family with regard to drug use. What

does seem clear from observation of individuals entering treatment

for drug abuse is that the drug reinforcer has become the preeminent influence in their lives, as evidenced by an overriding

concern with acquisition and effects of drugs as well as repeated

episodes of drug self-administration. From a behavioral perspective, the critical difference between abusers and nonabusers may

be the balance of reinforcers that control behavior. That is, the

drug reinforcer is preeminent in the life of an abuser and exerts

control over a large part of the behavioral repertoire, while in

nonabusers other, more socially acceptable reinforcers exert

preeminent control over behavior.

BEHAVIORAL APPROACHES TO TREATMENT

From a behavioral perspective, the main goal of drug abuse treatment is to change the relative dominance of behavior maintained by

different reinforcers and, in particular, to reduce the dominance

of behavior maintained by drug reinforcement while increasing behavior maintained by other reinforcers. Specific behavioral

methods available for decreasing undesirable drug-maintained

behaviors include extinction, satiation, and punishment, whereas

reinforcement techniques are most appropriate for increasing

desirable behaviors. Each of these approaches will be discussed

in this paper, with examples drawn primarily from the treatment of

opiate abuse since this is where most of the evaluation work has

been done.

Extinction

During extinction, the reinforcer is withheld following responses.

Thus, an extinction model requires that the drug self-administration response must occur in the absence of any reinforcing drug

effect. During the course of extinction, the frequency of such

unreinforced responding would gradually decrease and eventually

32
responding would stop. Narcotic antagonists such as naltrexone

are available that can provide a complete pharmacological blockade

of opiate drug effects. However, laboratory studies have shown

that human subjects do not continue taking opiate drugs during

pharmacological blockade, as would be needed for extinction of the

drug self-administration response (Mello et al. 1981, Meyer et al.

1976). Further, in clinical trials opiate antagonists have proven

to be a very unpopular treatment modality among opiate abusers;

retention drops off sharply during the first month of treatment

(National Research Council 1978). Thus, extinction does not

appear to be a viable approach for treatment of opiate abuse

because people are disinclined both to take opiate antagonists in

the first place and to self-administer opiate drugs during

antagonist blockade.

Satiation: Methadone Maintenance Treatment

Although methadone maintenance is generally conceptualized as a

purely medical or pharmacological treatment modality, methadone's

pharmacological effects during maintenance treatment can also be

viewed within a behavioral framework. Two related behavioral

pharmacological effects of methadone will be reviewed in this

section: first, the satiation of opiate drug effects provided by

methadone, and second, the reinforcing effects of methadone

itself.

Methadone satiation. During satiation, the organism is provided,

independently of responding, with liberal amounts of the reinforcer for which it has been working. In the case of a heroin

abuser, liberal amounts of heroin would be supplied, thus eliminating the need or desire to obtain additional amounts of the

drug, or both. Because most opiate drugs share pharmacological

cross-tolerance, however, it is possible to satiate opiate abusers

with any one of several opiate drugs. Methadone has been chosen

from among the available opiate drugs for use in the treatment of

opiate dependence because of its oral efficacy and relatively long

duration of action. Thus, during methadone maintenance treatment,

patients are provided with liberal daily amounts of an opiate drug

pharmacologically similar to the drug they have been abusing.

Providing the abuser with an opiate drug is analogous to feeding

an experimental subject before offering food as a reinforcer for

performance; the reinforcing potency of the food would be diminished, although possibly not eliminated. Similarly, the reinforcing potency of other opiate drugs is diminished during methadone

treatment, leading to a reduction in illicit opiate drug use.

Reduction in the reinforcing potency of opiate drugs during methadone treatment has been demonstrated in laboratory experiments. A

recent study by McCaul et al. (1983) compared the physiological

33
and subjective effects of intravenous hydromorphone (Dilaudid) in

nontolerant postaddicts and in methadone patients maintained on

50-60 mg/day. The postaddicts received doses of 2-6 mg hydromorphone, while the methadone patients received doses three times

higher (1O-18 mg). Figure 1 shows that hydromorphone produced

pupillary constriction and subjective reports of opiate intoxication (high) in the methadone maintenance subjects, but the magnitude of these drug effects was similar to that produced by the

smallest (2 mg) dose of hydromorphone in the nontolerant subjects.

FIGURE 1. Effects of intravenous hydromorphone (Dilaudid) on

pupil diameter and on subjective report of drug

intoxication. Data, shown separately, for opiatefree postaddict (open circles, N=5) and methadone

maintenance (closed circles, N=5) subjects were

collected 2 hours after drug or placebo (P) administration. Subjects rated their degree of drug high on

a scale of 0 to 100. Error bars are + 1 SEM.

Another study by Jones and Praada (1975) assessed the reinforcing

potency of opiate drugs during methadone maintenance by observing

self-administration when subjects were and were not maintained on

methadone. Subjects could ride an Exercycle to obtain daily 4-mg

hydromorphone doses during a lengthy study in which they were initially drug free, then given gradually increasing methadone doses

over a 6-week period, and finally maintained on 100 mg/day methadone. Hydromorphone self-administration declined as the methadone

dose was increased; most of the subjects stopped working for

hydromorphone about the time that the methadone dose reached

50 mg, although two subjects continued to take the hydromorphone

occasionally even while receiving the full methadone maintenance

dose. Similarly, opiate drug use may not be entirely eliminated

34
during methadone treatment in spite of the satiation and crosstolerance provided by the treatment drug.

Methadone reinforcement. While methadone diminishes the

reinforcing effects of other opiates via cross-tolerance and satiation, it also acts as a reinforcer by virtue of its own opiate

effects. A recent study by McCaul et al. (1982) demonstrated that

acute physiological and subjective effects were apparent following

administration of the daily dose of oral methadone in maintenance

patients. Four patients receiving daily doses of 40-80 mg methadone participated in sessions conducted 24 hours after ingestion

of the most recent methadone dose. During these sessions, subjects ingested either a placebo drink or a drink containing their

regular methadone dose. Physiological responses were monitored

continuously and subjective responses periodically for 3 l/2 hours

following ingestion of the drink. Figure 2a shows that the daily

methadone dose reliably decreased pupil diameter and increased

skin temperature, both of which are typical opiate drug effects.

Increased scores on the MBG (euphoria) scale of the Addiction

Research Center Inventory (Hill et al. 1963, Jasinski 1973) were

also observed in three of four subjects, as shown in figure 2b,

indicating that the daily dose produced measurable subjective

effects in these maintenance patients.

FIGURE 2a. Average effects of the daily oral methadone dose

(filled circles) or of methadone placebo (open

circles) on pupil diameter and skin temperature in

four subjects. Unconnected brackets represent mean

+ SD of baseline scores. Connected points and

vertical lines represent mean + SD of effects at 30-

minute postdrug intervals. (Mccaul et al. 1982.)

Copyright 1982, The C.V. Mosby Company.

35
FIGURE 2b. Effects of the daily oral methadone dose (filled

circles) or of methadone placebo (open circles) on

Morphine-Benzedrine Croup (MBG) scores of the Addiction Research Center Inventory in four individual

subjects. Unconnected brackets represent mean + SD

of baseline scores. Connected points represent

average change from control (predrug) observations.

(McCaul et al. 1982.) Copyright 1982, The C.V. Mosby

Company.

Another recent study by Stitzer et al. (1983b) demonstrated that

methadone dose increases are reinforcing by showing that maintenance patients would choose to self-administer supplemental

amounts of methadone in addition to their regular 50-70 mg maintenance dose, In this study, seven subjects chose between receiving

a sum of money ($1 or $5) or receiving an extra dose of methadone

(0,1,5,10,25, or 50 mg) in addition to their regular daily dose.

Before making each choice, subjects were informed of the amount of

methadone or money available on that occasion. Figure 3 shows

that extra methadone clearly acted as a reinforcer, since subjects

reliably took advantage of the self-administration opportunities.

Methadone was chosen over money on more occasions as the dose of

drug increased, and similar dose functions were obtained when the

monetary choice was $1 or $5. However, subjects chose the drug

more often at all doses when the alternative was $1 than when it

was $5, demonstrating that the reinforcing potency of a drug can

he modulated by the available environmental alternatives to drug

ingestion. The use of a treatment drug with reinforcing effects

36
suggests that patients would be attracted to and maintained in

treatment by the opportunity to receive methadone. The reinforcing properties of the daily methadone dose and of dose supplements

further suggests that methadone dose delivery or increases could

be scheduled in a contingent fashion to promote therapeutic change

in patient behaviors. In the following discussions of punishment

and reinforcement, interventions will be described that take

advantage of the reinforcing properties of methadone by making

delivery contingent on desirable behavior or by withdrawing

delivery as a consequence of undesirable behavior.

FIGURE 3. Percent of methadone doses self-administered by seven

methadone maintenance patients during informed

choices between money and extra methadone. Data are

shown separately for choices made when the monetary

alternative was $1 (closed circles) or $5 (open

circles). (Stitzer et al. 1983.) Copyright 1983,

The C.V. Mosby Company.

Punishment

The opportunity to continue receiving the full daily methadone

dose can be used in contingent punishment arrangements to suppress

illicit drug use or other undesirable behaviors. This section

will describe two punishment strategies involving methadone dose

delivery, contingent treatment termination, and contingent dose

reduction, and also will review studies that have evaluated the

therapeutic utility of these interventions.

37
Contingent treatment delivery. Contingent treatment delivery is

commonly employed as a patient management strategy in methadone

clinics; patients who are habitually uncooperative with clinic

regulations or who continue supplemental drug use, or both, are

typically threatened with termination of treatment. The threat is

then carried out with greater or lesser dispatch depending on the

rules and philosophy of the particular clinic and the willingness

of treatment staff to deal with problem patients. The overall

efficacy of this patient management strategy for producing change

in drug use and other outcome measures has not been evaluated,

although we might predict that efficacy would be related to the

consistency with which detox contingencies are enforced (Havassy

and Tschann 1984). Contingent methadone treatment termination has

been specifically evaluated, however, as a strategy in the treatment of alcoholic methadone maintenance patients.

A study by Liebson et al. (1978) elegantly demonstrated that continued methadone treatment delivery could motivate participation

in supervised disulfiram therapy among methadone maintenance

patients dually addicted to opiates and alcohol. The 25 patients

who participated had been or were about to be discharged from

other methadone treatment clinics because of behavioral problems

related to their alcoholism. All subjects were started on disulfiram during a 14-day loading period and were then randomly

assigned either to a control condition, in which they were provided with disulfiram and urged to take it at home, or to a

contingent condition, in which they were required to ingest

disulfiram each day at the clinic along with their methadone

dose. The consequence of disulfiram refusal for this group was

detoxification and termination of methadone treatment. The

experimental condition was scheduled to remain in effect for 6

months, followed by transfer to the control condition. Subjects

could remain in the control condition indefinitely if they were

doing well, but evidence of heavy drinking resulted in transfer to

the contingent condition. As shown in figure 4, patients randomly

assigned to the contingent disulfiram condition did much better on

measures of abstinence (percent of days drinking) and social functioning (data shown are for arrests per 100 patient days in

treatment) than did patients assigned to the control condition.

In fact, patients ended up spending more time in the contingent

(3,497 days) than in the control (1,634 days) condition because of

the provision that control subjects could switch conditions if

they showed evidence of heavy drinking. This study demonstrated

that contingent methadone treatment termination effectively

promoted participation in supervised disulfiram therapy among

alcoholic methadone maintenance patients. The generality of this

finding to other drug use remains to be explored.

38
FIGURE 4. Effects of contingent and noncontingent disulfiram

ingestion on percent of days drinking and on number

of arrests per 100 patient days. Drinking data are

for 12 subjects who remained in treatment long enough

to be assigned at least once to the treatment and

control conditions; arrest data are for all (N=25)

study participants. (Liebson et al. 1978.) Copyright 1978, Annals of Internal Medicine.

Contingent methadone dose decreases. In this contingency management system, discrete dose decreases are arranged as a consequence

of undesirable behavior, while the regular dose is restored upon

evidence of appropriate behavior. In our research clinic, for

example, this system has been used to promote regular payment of

the required clinic service fee. As soon as a patient accumulates

a specified amount of debt, a 21-day methadone dose reduction

schedule is started, but the original dose can be reinstated as

soon as the clinic debt is paid in full. Similarly, dose

decreases could be arranged as a consequence of drug-positive

urine samples; restoration of the original dose would depend upon

provision of drug-free urines. This strategy has an advantage

over contingent treatment termination in that it provides a

discrete aversive event (dose reduction) that can be programmed to

occur after each instance of undesirable behavior rather than a

single catastrophic event (treatment termination) that occurs

after many instances of undesirable behavior. It should be noted,

however, that from a pharmacological viewpoint, contingent dose

decreases may not offer the best approach since they reduce the

efficacy of methadone as a treatment drug and decrease the likelihood of retaining the patient in treatment.

One study by Glosser (1983) attempted to evaluate the effects of a

contingent dose delivery system on illicit drug use of methadone

39
maintenance patients. The program used was a token economy system

in which points could be earned for attending the clinic on time

each day, providing frequent urine samples, providing drug-free

urine samples, attending a weekly counseling session, completing

assessments, and fulfilling contracted activities. About onethird of the points depended on providing drug-free urine samples.

Points were needed to purchase the full daily methadone dose, and

any deficits in points resulted in a small (1 mg per deficit

point) decrease in dose. However, the dose could be restored

fairly rapidly if the patient earned a full complement of points

on several consecutive days. Subjects exposed to the token economy system from the start of their treatment enrollment (N=86)

showed less urinalysis evidence of illicit drug use than did a

historical control group (N=20). For example, during their third

treatment month, the control group submitted 35 percent drugpositive samples, while the experimental group submitted 14 percent positive samples. Because of the use of a historical control

group rather than random assignment, differences in baseline

levels of drug use or confounding by other concurrent environmental changes cannot be excluded as possible explanations for this

group difference. The most convincing data presented were for 4

of 11 clients who changed during their enrollment from the traditional clinic rules to the token economy system. These patients

showed a marked reduction in illicit drug use. Thus, the study

suggests that a token economy system based on avoiding methadone

dose reductions can have a beneficial impact on illicit drug use

in at least a subgroup of maintenance patients.

Reinforcement

Reinforcement is a behavioral technique that is particularly useful for increasing the frequency of desirable behaviors. Since

drug use is the primary focus of concern in drug abuse treatment,

one behavior that can be reinforced is abstinence from drugs. An

additional or concurrent approach would be to reinforce behaviors

that compete with drug use or that lead toward improved social

integration and functioning. This section will describe two ways

in which methadone delivery can be used to reinforce behavior

change--contingent dose increases and contingent take-home doses--

and also will review studies that have evaluated the therapeutic

utility of these interventions.

Contingent methadone dose increases. As previously mentioned,

methadone maintenance patients may continue to supplement their

regimen occasionally with illicit opiate drugs while in treatment.

The typical clinic response to evidence of ongoing opiate supplementation is to raise the dose in order to increase the level of

satiation and cross-tolerance achieved, although the efficacy of

this procedure is at present uncertain (Gossop et al. 1982,

Havassy and Tschann 1984). A preliminary study conducted at our

research clinic suggests that efficacy may be enhanced by making

discrete dose increases contingent upon opiate-free urine

specimens. Three maintenance patients were selected because they

40
persistently submitted opiate-positive urine samples. Following a

baseline evaluation period, these subjects were studied under both

a contingent and a noncontingent dose increase procedure, with

order of exposure to the two conditions counterbalanced across

subjects. During the noncontingent procedure, subjects received a

blind 25-mg increase in addition to their regular 50-mg/day methadone dose. The increase remained in effect for 6 weeks and then

was gradually withdrawn. During the contingent procedure, these

same subjects could request up to 25 mg of extra methadone daily

providing that their most recent Monday, Wednesday, or Friday

urine test result had been opiate-negative. As shown in figure 5,

reduction in drug use was observed more consistently and more

immediately under the contingent than under the noncontingent dose

increase procedure. These preliminary data suggest that scheduling dose increases contingent on opiate-free urines may be a more

effective way of suppressing supplemental opiate use than providing noncontingent dose increases. To the extent that a methadone

dose increase functions as a reinforcer, this procedure may also

be useful for promoting improvement in behaviors other than

illicit opiate drug use.

FIGURE 5. Effects of contingent and noncontingent methadone dose

increases on percent of opiate-positive urine samples

in three individual subjects. Data are summarized

for 2-week blocks prior to (open bars) and during

(closed bars) the experimental interventions. During

the noncontingent procedure, subjects received a

blind 25-mg increase in their daily methadone dose;

during the contingent procedure subjects could

request daily 25-mg increases only if their most

recent urine sample had been opiate free.

Contingent methadone take-how doses. Methadone take-home doses

allow patients to carry doses away from the clinic and thus

41
eliminate the necessity for daily clinic attendance. Several

studies have demonstrated the potency of methadone take-homes as a

reinforcer for methadone maintenance patients. One study by

Stitzer et al. (1977) showed that counseling attendance improved

among a group of chronic nonattenders when they could receive

weekend take-home privileges each time they attended a counseling

session of a specified duration during the week. A second recent

study (Stitzer and Bigelow 1984) used contingent take-home methadone doses to promote regular payment of clinic fees. The takehome reinforcement procedure operated concurrently with the

standard clinic policy dictating that subjects would begin detoxification if they failed to pay their fees for long periods of

time. Subjects were selected for this study if they paid their

fees sporadically during an 8-week baseline evaluation period.

Following the baseline evaluation, subjects were exposed successively in counterbalanced order to a take-home and to a rebate

intervention, each of which was in effect for 8 weeks. During the

take-home program, subjects could earn a single take-home dose for

use the following day whenever they paid their fee on Wednesday.

During the rebate program, a $2 discount was offered if fees were

paid on Wednesday. Figure 6 shows that the contingent take-home

effectively increased Wednesday payments, while the rebate program

was much less effective. This study demonstrated the potency of

the take-home privilege as a reinforcer; in this case, the contingent take-home opportunity promoted a more desirable pattern of

clinic fee payments.

FIGURE 6. Average number of clinic fee payments detivered on

Wednesday is shown during three 8-week study phases:

baseline evaluation, contingent rebate program, and

contingent take-home program. Data are based on 5

subjects who participated in all three study phases.

Error bars are + 1 SEM. (Stitzer and Pigelow 1984) 

Copyright 1984 Elsevier Scientific Publishers.

Ireland Ltd.

42
Contingent take-home privileges have also been used effectively to

reduce supplemental drug use in methadone maintenance patients.

In one study (Stitzer et al. 1979), a portion of the benzodiazepine use of chronic benzodiazepine abusers was observed at

the clinic by prescribing a 20-mg dose, which could be requested

daily at the dispensary window. During baseline periods, virtually all the available drug was requested. However, when patients

were offered the opportunity to receive a take-home methadone dose

following benzodiazepine refusal, only 11 percent of available

doses were requested. In a second study conducted with chronic

benzodiazepine abusers (Stitzer et al. 1982), subjects were

offered a choice of reinforcers twice weekly as a consequence of

providing benzodiazepine-free urine samples. The choices included

a take-home dose, a $15 payment, and a 20-mg single-day dose

increase. Reduced benzodiazepine use was noted in 8 of 10 subjects during the contingent intervention, while half of the

subjects remained benzodiazepine free throughout the 3-month

intervention. Take-homes were chosen on about half the occasions

that reinforcers were earned; money was selected on the remaining

occasions.

Thus, several studies have shown that the methadone take-home

privilege can be used in contingent arrangements to promote

improvement in a single target behavior. It may also be possible

to implement clinic-wide contingency management systems that

promote simultaneous improvement in several target behaviors.

Milby et al. (1978) evaluated one clinic-wide program in which

methadone maintenance patients could earn take-home privileges by

delivering drug-free urine samples for 7 consecutive weeks, maintaining a productive status (work or school), and being generally

cooperative with clinic rules. Once take-home privileges had been

gained, they could be lost again if the client changed his or her

productive status or began delivering drug-positive urines. The

effect of the take-home program was specifically related to the

requirements of the contingency; a large number of consecutive

clean urines was required and an increase in long strings of

consecutive clean urines was observed. For example, twice as many

patients showed seven or more consecutive clean urines in the 2

months after the contingency was put in effect than in the 2

months before. However, overall rates of positive urine samples

were not altered by the program, suggesting that some patients

might have increased their drug use above original levels following unsuccessful attempts at meeting the take-home eligibility

criterion. An increase in productive activity was also reported

following implementation of the take-home policy, although the

methods used to verify the information supplied by patients are

not clearly described. Although the program designed by Milby

might not be optimal for engendering behavior change, this study

generally supported the efficacy of contingent take-homes for

promoting improvement in drug use and productive activity of at

least some methadone maintenance patients.

43
RECOMMENDATIONS FOR CLINIC-HIDE APPLICATION OF CONTINGENT

REINFORCEMENT SYSTEMS

Studies reviewed in previous sections have shown that methadone

can be delivered or withheld in contingent arrangements to promote

improved outcomes in drug abuse patients. The potency and specificity of these contingent reinforcement and punishment interventions has generally been impressive in the short-term studies

conducted to date. Thus, these studies suggest that contingency

management procedures involving methadone dose delivery may be a

clinically useful adjunct in methadone treatment. The studies

certainly suggest that additional research is warranted, including

longer term clinical trials of these interventions. There are

several issues that must be considered if contingency management

programs are to be implemented on a clinic-wide basis and about

which more information is needed before definitive recommendations

can be made as to optimal implementation approaches. The most

important issues concern 1) the choice of reinforcement versus

punishment approaches, 2) the choice of target behaviors, and

3) the extent to which contingencies should be implemented uniformly for all clinic patients versus individually for different

patients. Each of these issues will be considered in subsequent

sections.

Choice of Reinforcement Versus Punishment

Four factors deserve consideration in making choices between positive reinforcement and aversive or punishment interventions.

These factors are 1) efficacy of the intervention, 2) ease of

implementation, 3) staff acceptance, and 4) patient acceptance.

Among the reinforcers and punishers available at the methadone

clinic, only the take-home privilege has received widespread evaluation for efficacy. Contingent take-homes have been effective in

managing several problem behaviors encountered in drug abuse

patients, including supplemental drug use. The efficacy of aversive techniques has received little systematic evaluation to date.

More research is needed about the relative efficacy of reinforcement versus punishment techniques: these may be differentially

effective in altering different target behaviors or differentially

effective in patients with different characteristics. The efficacy of techniques that combine reinforcement and punishment also

heeds to be explored.

None of the available contingency management techniques stands out

as particularly easy or difficult to implement. Both methadone

dose alteration and take-home interventions require some advance

preparation and additional recordkeeping on the part of the nursing staff. In any contingency management system, it is important

to develop cross-checks to ensure that reinforcers or punishers

are delivered accurately according to the specifications of the

system.

44
Acceptance on the part of both staff and patients wou'd probably

be better for reinforcement than for punishment systems, although

the attitude of the staff is likely to be influenced by existing

treatment philosophies of the clinic. Acceptance can be measured

directly with questionnaires, but it is also likely to be

reflected in objective outcome measures. Treatment retention

should in part reflect patient acceptance, while staff acceptance

is likely to influence efficacy measures since the staff can sabotage systems they do not like. Future evaluation research should

take these acceptance factors into account.

Choice of Target Behaviors

There is little doubt that ongoing drug use during treatment

should be the first clinical concern and intervention priority in

drug abuse treatment. Further, a contingency management approach

may be particularly applicable in the case of supplemental drug

use since it is questionable whether any new skills are required

to give up drug use; rather, it may be that environmental reinforcement for doing so is lacking. The choice of additional

therapeutic goals could depend on the level of patient

functioning. For patients who are uncooperative and manipulative

at the clinic, contingencies based on behavior at the clinic would

be most appropriate, including attending on time, limiting time

spent at the clinic, attending counseling, and paying required

fees. For patients who are cooperative at the clinic, a focus on

improved vocational status or interpersonal relations might be

appropriate. Most clinics focus uniformly on employment as the

most important secondary goal (after elimination of drug use) for

their patients and routinely deliver take-home privileges to

employed patients. However, employment status may not be the most

appropriate target for delivery of contingent reinforcers if the

intent is to improve the vocational status of clinic patients.

Many patients may obtain or continue legitimate employment after

enrolling in treatment irrespective of the availability of takehomes for employed patients, while chronically unemployed patients

may lack the relevant skills and work history needed to obtain and

keep a job. The vocational status of this unemployed group might

best be influenced by providing reinforcement for participation in

needed skills training programs outside the clinic rather than

providing incentives for employment per se.

Another potentially important goal in rehabilitation of drug abuse

patients is establishment of satisfying interpersonal relations

that do not promote drug abuse. Some drug abusers may have marital and family problems that require interventions beyond the

capabilities and skills of drug abuse counselors. Others may have

psychiatric problems or social skills deficits that interfere with

forming satisfying interpersonal relations. Since drug abuse

treatment clinics cannot possibly provide the full spectrum of

ancillary treatment services that might be useful for these

patients, the best strategy for improving their interpersonal

functioning may be to provide reinforcement for participation in

45
programs outside the clinic where needed skills and specialized

therapies can be obtained. Patients who are functioning well

interpersonally but are satisfied with family and friendship

associations that promote and sustain their drug use, or who lack

ready access to sources of friends who do not use drugs, can

receive reinforcement for participation in community activities

where they may meet new friends who are nonusers.

Uniform Versus Individualized Programs

The simplest way to implement a contingency management program

would be to set up uniform contingencies for all clinic patients.

For example, take-home privileges could be offered for providing

drug-free urine samples and for exhibiting specific responsible

behaviors at the clinic such as attending scheduled counseling

sessions and paying the required fee. A system in which weekend

take-home privileges were available to all patients for providing

drug-free urine samples on Monday would have several advantages.

First, it would provide a clinic-wide focus on the most pertinent

treatment goal, elimination of illicit drug use. Secondly,

although a drug-free sample delivered on Monday does not preclude

the possibility that drug use occurred over the weekend, this

system would tend to promote relatively circumspect and controlled

amounts of use. Thirdly, with a Monday urine collection schedule,

there would be a reasonable chance of receiving results from an

outside testing laboratory in sufficient time to authorize takehome privileges for the following weekend. If an onsite urine

testing system were available, additional urine samples could be

collected and tested during the week in order to more fully

monitor drug use, and the results of these tests could also be

included in the contingent take-home plan. A contingency management system that specified uniform requirements for obtaining

privileges and that was based on concrete behaviors observable at

the clinic would help ensure smooth clinic operation and could be

most easily implemented and evaluated.

In a somewhat more flexible contingency management system a specified number of take-homes might be available for dispensing by

counseling staff depending on the therapeutic goals of individual

patients. The specific requirements for earning take-homes would

be chosen from a clearly defined list of alternatives, which might

include drug-free urine, counseling attendance, cooperation with

other clinic rules, or verified participation in ancillary treatment services or community activities designed to promote improvement in vocational or social adjustment.

Experience has shown, however, that individualized contingency

management programs are difficult to design and implement for

several reasons (Bigelow et al. 1980). First, it is difficult for

a treatment staff untrained in behavior therapy techniques to

specify concrete behavioral steps that are manageable for patients

but that will effectively lead toward larger ultimate goals.

Second, it is difficult for treatment staff to avoid being

46
diverted from ongoing treatment goals by crisis situations, which

may arise frequently for patients with unstable lifestyles.

Third, whenever reinforcers are offered for activities that occur

outside the clinic, it is frequently difficult to verify that

patients actually engaged in the specified activities. Finally,

there are difficulties in ensuring that privileges are dispensed

consistently and accurately according to the specifications of

individualized contingency management contracts. In spite of

these difficulties, it seems worthwhile to consider systems that

allow for flexibility in dispensing at least some program privileges, since there are potential advantages to be gained from

clarifying treatment priorities for individual patients, formulating concrete therapeutic goals, and breaking large goals down

into manageable steps.

In summary, a contingency management system is recommended in

which some privileges are uniformly available to all patients

based upon abstinence from illicit drug use, since this is the

primary concern of drug abuse treatment, while additional privileges are available for delivery on an individualized basis as a

consequence of cooperation with clinic regulations or as a consequence of participation in needed skills training, psychotherapy

programs, or community activities. At present, the use of positive reinforcement rather than punishment techniques is suggested

since positive reinforcement may be associated with good therapeutic outcomes as well as more positive staff attitudes and

better treatment retention.

SUMMARY

The goal of drug abuse treatment is to decrease the dominance of

drug-related behaviors while enhancing the dominance of alternative socially acceptable behaviors. The behavioral techniques of

extinction, satiation, and punishment can be used to suppress

undesirable behaviors, and reinforcement can be used to enhance

desirable behaviors. Methadone maintenance offers unique advantages for treatment of opiate abuse since methadone satiates the

drug abuser, thereby reducing the reinforcing efficacy of illicit

opiate drugs, while also serving as a reinforcer whose delivery in

the treatment setting can be used in contingent arrangements.

Short-term efficacy has been demonstrated in studies that used

contingent treatment termination or contingent dose decreases as

punishing events and contingent dose increases or contingent takehome privileges as reinforcing events to promote reductions in

drug use and cooperation with clinic rules. Systematic use of

dose adjustments and take-home privileges may be a useful adjunct

to methadone maintenance treatment, having a positive impact both

on client outcomes and clinic operation. Rehabilitation efforts

might also benefit if delivery of reinforcers available at the

clinic is contingent upon participation in skills training and

therapy programs or community activities outside the drug abuse

clinic.

47
REFERENCES

Bigelow, G.E.; Stitzer, M.L; Lawrence, C.; Krasnegor, N.;

D'Lugoff, B.; and Hawthorne, J.W. Narcotics addiction

treatment: Behavioral methods concurrent with methadone

maintenance. Int J Addict 15(3):427-437, 1980.

Deneau, G.; Yanagita, T.; and Seevers, M.H. Self-administration

of psychoactive substances in the monkey. A measure of

psychological dependence. Psychopharmacology 16:30-48, 1969.

Glosser, D.S. The use of a token economy to reduce illicit drug

use among methadone maintenance clients. Addict Behav 8:93-104,

1983.

Gossop, M.; Strang, J.; and Connell, P.H. The response of outpatient opiate addicts to the provision of a temporary increase

in their prescribed drugs. Br J Psychiatry 141:338-343, 1982.

Hall, S.M. Methadone treatment: A review of the research

findinqs. In: Cooper, J.R.; Altman, F.; Brown, B.S.; and

Czechowicz, D., eds. Research on the Treatment of Narcotic

Addiction. State of the Art. National Institute on Drug Abuse

Treatment Research Monograph Series. DHHS Pub. NO. (ADM)

83-1281. Washington, D.C.: Supt. of Docs., U.S. Govt. Print.

Off., 1983. pp. 575-632.

Havassy, B.E., and Tschann, J.M. Chronic heroin use during methadone treatment: A test of the efficacy of high maintenance

doses. Addict Behav 9:57-65, 1984.

Hill, H.E.; Haertzen, C.A.; Wolbach, A.B.; and Miner, E.J. The

Addiction Research Center Inventory: Standardization of scales

which evaluate subjective effects of morphine, amphetamine,

pentobarbital, alcohol, LSD-25, pyrahexyl and chlorpromazine.

Psychopharmacologia 4:167-183, 1963.

Jasinski, D.R. Assessment of the dependence liability of opiates

and sedative-hypnotics. In: Goldberg, L., and Hoffmeister, F.,

eds. Bayer-Symposium IV, Psychic Dependence. Berlin:

Springer-Verlag, 1973. pp. 160-170.

Johanson, C.E., and Schuster, C.R. Animal models of drug selfadministration. In: Mello, N.K., ed. Advances in Substance

Abuse: Behavioral and Biological Research. Vol.2. Greenwich,

Conn.: JAI Press, 1982.

Jones, B.E., and Praada, J.A. Drug-seeking behavior during

methadone maintenance. Psychopharmacologia 41:7-10, 1975.

Kelleher, R.T., and Goldberg, S.R. Control of drug taking

behavior by schedules of reinforcement. Pharmacol Rev 27:291-

299, 1975.

Klajner, F.; Hartman, L.M.; and Sobell, M.B. Treatment of

substance abuse by relaxation training: A review of its

rationale, efficacy and mechanisms. Addict Behav 9:41-55, 1984.

Liebson, I.A.; Tommasello, A.; and Bigelow, G.E. A behavioral

treatment of alcoholic methadone patients. Ann Int Med

89(3):342-344, 1978.

McCaul, M.E.; Bigelow, G.E.; Stitzer, M.L.; and Liebson, I.A.

Short-term effects of oral methadone in methadone maintenance

subjects. Clin Pharmacol Ther 31(6):753-761, 1982.

48
McCaul, M.E.; Stitzer, M.L.; Bigelow, G.E.; and Liebson, I.A.

Intravenous hydromorphone: Effects in opiate-free and methadone

maintenance subjects. In:

Dependence 1982.

Harris, L.S., ed. Problems of Drug

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Monograph 43. DHHS Pub. No. (ADM) 83-1264. Washington, D.C.:

Supt. of DOCS., U.S. Govt. Print. Off., 1983. pp. 238-244.

Mello, N.K.; Mendelson, J.H.; Kuehnle, J.C.; and Sellers, M.S.

Operant analysis of human heroin self-administration and the

effects of naltrexone. J Pharmacol Exp Ther 216(1):45-54, 1981.

Meyer, R.E.; Mirin, S.V.; Altman, J.L.; and McNamee, H.B. A

behavioral paradigm for the evaluation of narcotic antagonists.

Arch Gen Psychiatry 33:371-377, 1976.

Milby, J.B.; Garrett, C.; English, C.; Fritschi, 0.; and Clarke,

C. Take-home methadone: Contingency effects on drug-seeking

and productivity of narcotic addicts. Addict Behav 3:215-2213,

1978.

National Research Council, Committee on Clinical Evaluation of

Narcotic Antagonists. Clinical evaluation of naltrexone

treatment of opiate-dependent individuals. Arch Gen Psyhiatry

35: 335-340, 1978.

Stitzer, M.L., and Bigelow, G.E. Contingent methadone take-home

privileges: Effects on compliance with fee payment schedules.

Drug Alcohol Depend, 13:395-399, 1984.

Stitzer, Bigelow, G.E.; and Liebson, I.A. Reducing benzodiazepine self-administration with contingent reinforcement.

Addict Behav 4:245-252, 1979.

Stitzer, M.L.; Bigelow, G.E.; and McCaul, M.E. Behavioral

approaches to drug abuse. In: Hersen, M., and Eisler, L., eds.

Progress in Behavior Modification. Vol. 14. New York:

Academic Press, 1983a. pp. 49-124.

Stitzer, M.L.; Bigelow, G.E.; Liebson, I.A.; and Hawthorne, J.W.

Contingent reinforcement for benzodiazepine-free urines:

Evaluation of a drug abuse treatment intervention. J Appl Behav

Anal 15:493-503, 1982.

Stitzer, M.L.; McCaul, M.E.; Bigelow, G.E.; and Liebson, I.A.

Oral methadone self-administration: Effects of dose and

alternative reinforcers. Clin Pharmacol Ther 34(1):29-35,

1983b.

Stitzer, M.L.; Bigelow, G.E.; Lawrence, C.; Cohen, J.; D'Lugoff,

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a methadone maintenance program. Addict Behav 2:9-14, 1977.

49
AUTHORS

Maxine L. Stitzer, Ph.D.

George E. Bigelow, Ph.D.

Mary E. McCaul, Ph.D.

Johns Hopkins University

School of Medicine

and

Francis Scott Key Medical Center

Department of Psychiatry, D-5 West

4940 Eastern Avenue

Baltimore, MD 21224

50
ONE-PERSON FAMILY THERAPY:

A MODALITY OF BRIEF STRATEGIC

FAMILY THERAPY

Franklin H. Foote,

Jose Szapocznik, William M. Kurtines,

Angel Perez-Vidal, Olga K. Hervis

INTRODUCTION

The literature substantiates the effectiveness of family therapy

approaches with a number of presenting problems. In a major

national survey of 2,012 agencies offering services to drug

abusers, 93 percent of the respondents indicated family therapy as

the treatment of choice with drug abusers (Coleman and Davis

1978). Despite this wide acceptance, considerable evidence suggests that inducing families of drug abusers to participate in

extended treatment is extremely difficult. Coleman and Davis

(1978), as well as other researchers (Stanton 1979, Stanton and

Todd 1981), document the difficulty of engaging and retaining drug

abusers' families in treatment.

The NIDA-sponsored Brief Strategic Family Therapy (BSFT) project

developed and refined the BSFT conceptual model to address some of

the difficulties encountered with family therapy. In doing so,

this project developed a cost-effective and therapeutically

effective approach to family therapy for use with drug-abusing

adolescents. BSFT's therapeutic effectiveness is summarized in

the Research Findings section of this paper. BSFT's costeffectiveness results from its brevity (15 weekly sessions or

fewer) and rate of retention. Thus BSFT capitalizes on the

therapeutic effectiveness of family therapy while increasing its

cost-effectiveness.

Two modalities were developed, applying the BSFT conceptual

framework. The first application, Conjoint Family Therapy (CFT),

is a refinement of previously existing structural systems family

therapy (Minuchin 1974), with the entire family present for most

therapy sessions. However, the therapy is conducted in a timelimited and strategic manner. Several publications describe CFT

(Szapocznik et al. 1983a, 1983b) and its precursors (Frankel 1984,

Haley 1976, Madannes 1981, Minuchin 1974, Minuchin and Fishman

1981). The second and more innovative modality, One-Person Family

Therapy (OPFT), is emphasized here. Both modalities were

51
experimentally evaluated in a sample of Hispanic families with

drug-abusing adolescents.

This paper provides an overview of the BSFT conceptual framework

and an applied discussion of OPFT. The results of the experimental evaluation of the two therapy modalities are summarized and

directions for future research are presented.

BASIC CONCEPTS

The BSFT conceptual framework makes two basic assumptions about

the nature of families: the family and its members are a system,

and family interactions occur in typical patterns called structures. In addition, BSFT uses two general guidelines to govern

therapy: it should be strategic, that is, problem-focused and

pragmatic, and it should be time-limited. Finally, BSFT follows

three therapeutic strategies: the use of joining for entering the

family system, experiential diagnosis to plan restructuring, and

performance-based restructuring techniques. These seven elements

define BSFT and are discussed below.

Assumptions About Families

The systems perspective in RSFT implies that individuals and individual behavior can be understood only in terms of their context--

the system (e.g., the family, the community) and subsystems (e.g.,

the parental unit, the sibling unit) to which the individual

belongs. Additionally, individual behavior is viewed as both

interactive and interdependent. Thus, each family member's

behavior is fundamentally different from what it would be if that

individual could act in isolation.

Families in which adolescent drug abuse occurs tend to identify

the adolescent as the sick patient. Within a family systems

framework, this person is referred to as the family's Identified

Patient (IP). At the time of presentation, the family's typical

expectation of therapy is that the IP needs to be changed. The

BSFT therapist, however, recognizes that, although one of the

members manifests drug abuse symptoms, those symptoms are maintained because the entire family participates in maladaptive

patterns of interaction. Treatment, therefore, targets the family

as a whole.

Because of the systems assumption, BSFT examines interactions

between people rather than individual behavior in isolation.

Another basic assumption of BSFT is that a family tends to repeat

these interactions, forming typical behavior patterns for conducting business among its members and within its environment. These

typical or habitual patterns of interaction define a family's

structural organization. Dysfunction results from the family

system's attempts to resolve a problem by applying a maladaptive

pattern of interaction. A problem arises and the family responds

with a particular set of interactions, not because that response

52
is adaptive and will be effective in resolving the problem, but

because that particular set of frequently repeated interactions

has become habitual. Thus, the purpose of structural therapy is

to facilitate the emergence of new patterns of interaction (i.e.,

family structures) that resolve problems effectively.

General Therapeutic Guidelines

In BSFT, therapy is strategically oriented. As part of this strategic orientation, therapy is problem-focused. The problem-focus

requires that the family structures (patterns of interaction) targeted for change are those that directly affect the drug use or

other symptomatic behavior. In addition, the presenting complaints such as drug abuse are used as the content through which

the family is engaged in therapy. A strategic orientation also

implies a high degree of pragmatism. Thus, BSFT modalities use

whatever techniques lead to the most efficient, permanent, and

adaptive structural change in the family system.

Another BSFT characteristic is that it is time-limited. Research

and clinical evidence indicate that explicit temporal limitations

that are strictly adhered to may facilitate and accelerate the

therapeutic process (McGee and Williams 1971, Muench 1965).

BSFT's preferred treatment length is 8 to 12 weekly therapy

sessions, although a maximum of 15 sessions may be necessary.

Therapeutic Strategies

BSFT uses a joining strategy for entering the family system in a

manner designed to avoid systemic resistance to change. The

therapist joins by initially supporting the family and mimicking

its style, affect, and activity. Once the therapist has found a

way to fit into the family system and formed a positive relationship with each of its members, he/she quickly establishes a

leadership position in the system. Thus, as a result of joining,

a new system consisting of the family plus the therapist is

formed.

Another element of BSFT is the strategy of developing an experiential diagnosis in order to plan how to restructure the family.

The therapist diagnoses the family structure based on interactions

occurring in the therapist's presence. In practice, the diagnosis

occurs throughout the joining process. The diagnosis is experiential in two senses: not only is it based on behavioral interactions, but also it is through the joining process that the

therapist is able to experience these interactions in the same way

that family members experience them. After the family's structure

is assessed, a series of interventions is strategically designed

to restructure dysfunctional patterns of interaction. This

planning focuses the therapeutic process, thereby shortening it.

Finally, the BSFT conceptual framework uses the strategy of

performance-based restructuring. The BSFT therapist facilitates a

53
change in the family's organization so that the family members can

achieve more adaptive patterns of family interaction. The therapist directs or manipulates improved ways of relating that must be

performed by family members during therapy. Once more adaptive

interaction patterns have been achieved within therapy sessions,

the therapist assigns homework so these patterns can be successfully performed without the therapist's direct assistance.

Brief Strategic Family Therapy is present- and future-oriented.

Its goal is not the exploration of the past, but rather the

manipulation of the present (Minuchin 1974) as a tool for change.

In order to work toward this goal, the therapist examines sets of

interactions, diagnoses those that are pathological, and plans

strategies to restructure these interaction patterns in order to

implement change. BSFT's cost-effectiveness derives from its use

of strategic interventions, explicit a priori time limitations,

and the joining strategy, which gives the therapist access to the

family and the ability to maneuver effectively.

ONE-PERSON FAMILY THERAPY

The purpose of One-Person Family Therapy (OPFT) is to accomplish

BSFT's goals (i.e., reduction of drug abuse and improved functioning of the whole family) while working primarily with one person

in therapy. By working with only one family member in most therapy sessions, OPFT enhances BSFT's strategic qualities. A corollary of the assumption that families are interactive systems that

is critical to the development of OPFT is the Principle of

Complementarity. It states that if a system is to maintain itself

and its typical patterns of behavior, the behavior of each member

must coordinate with, be maintained by, and be contingent upon the

behavior of each and every one of the family members. Thus, if

the behavior of one person in a family changes, then the other

family members also have to change their behavior.

What follows is a brief discussion of the four major steps in

OPFT: 1) the diagnostic interview, 2) choosing the IP, 3) joining, and 4) restructuring. These steps in OPFT will be explained

by presenting the case of David S., a 16-year-old Hispanic who

took methaqualone hydrochloride (Quaaludes) at least weekly and

smoked marijuana daily. He had run away from home, and the

Juvenile Court referred him for therapy. A fuller discussion of

OPFT can be found in Szapocznik et al. (1984, in preparation-a).

Diagnostic Interview

In the case of David, the first step was an interview and diagnostic session with his entire family. Such an interview, although

not absolutely essential, makes it easier to understand the family

structure (patterns of interaction). The initial interview

revealed that the family identified David as the principal

repository of blame for the family's unhappiness, i.e., as the IP.

The assessment of family interactions indicated that the mother

54
overprotected David. The father, on the other hand, labeled his

son as hopeless, denigrating him for his failures. In our work

with Hispanic adolescent drug abusers, this pattern of an overly

protective mother and a punitive father is common. In addition,

David's mother and father continually bickered throughout the

assessment session, but consistently diffused the conflicts

existing between them by focusing on David's "problems." Thus,

several dysfunctional structures were revealed in this initial

interview.

How to Choose the OP

The second step in the OPFT procedure is choosing the One Person

(OP) for therapy. A number of factors should be considered,

including: 1) rigidity of the IPhood (i.e., the degree to which

all the family's problems are blamed only on the IP), 2) centrality in family interactions, 3) power in the family, and 4) availability in both a psychological and practical way.

In this case, the identified patient--David--was selected as the

OP, for several reasons. The first was the rigidity of the

IPhood. David's family was very unwilling to accept the possibility that anything could be wrong with the family other than David.

A second reason for choosing David was his centrality. By virtue

of his being the IP, most arguments within the family centered

around him. Finally, David was eminently available because of a

court mandate.

Joining

Establishing a therapeutic alliance. As already described, in

BSFT the initial task of the therapist is to join the family

system. In OPFT, because the entire family generally is not

available during most therapy sessions, the therapist enters the

family, as well as directs change, through the OP. To accomplish

this, a strong therapeutic alliance is established with the OP.

The OPFT therapist continues to track the family's characteristic

patterns of interaction through the OP's perceptions.

For example, when David presented himself for the first session,

he was dressed in a black jacket and gave the impression of a

tough, "streetwise" adolescent who took pride in flaunting his

drug experiences. Although initially cautious and cool, later he

began to enthusiastically recount experiences he had when he ran

away from home. This situation provided the opportunity for the

therapist to begin the joining process. The therapist listened

intently and allowed David to savor his bold adventure. David was

allowed to experience the opposite of his initial self-blame and

negativism about what he had done. By listening attentively, the

therapist shared a critical experience with the patient and established a therapeutic alliance that provided a foundation on which

to begin to assess the family structure.

55
Enactment analogue. In structural family therapy with the entire

family present, a necessary component of joining is to encourage

enactment of the typical family interaction patterns in the presence of the therapist. This aids in both entering the family

system and making the experiential diagnosis. In OPFT, however,

because just one person is present, only an enactment analogue is

possible--a representation of the family's characteristic interactional patterns in lieu of direct observation.

In OPFT, when the OP is asked to represent her/his family, what

the OP usually represents is the behavior of others rather than

the self. The therapist assumes from the Principle of Complementarity that for the system to maintain itself, the OP must behave

in a fashion that complements the reported behavior of others,

i.e., the OP has introjected the kinds of behaviors that complement the behavior of others in the family. Because the OP tends

to perceive the other family members' behaviors but not her/his

own, in the enactment analogue the OP is requested to represent

the other family members' behaviors. A full picture of the

family's structure (patterns of interaction) emerges when the

family's behaviors as represented by the OP and the behaviors the

therapist has assumed the OP has introjected are brought together.

When the therapist inquired about David's perception of the problem in the family, David responded by complaining that he felt

humiliated by his family. His relationship with an older girlfriend provided the therapist with some content to use in further

assessing the family interactional patterns, revealing that

David's place in the family structure had him in two conflicting

roles: his mother's innocent baby ("My poor little one, that

terrible woman is misleading you") and his father's no-good bum

("You are no son of mine to go with a woman like that!"). The

enactment analogue, then, provided the therapist with an experiential diagnosis used to plan the restructuring described below.

Restructuring

Restructuring refers to the actual interventions that are designed

to change family interaction patterns. In OPFT, the therapist

directs changes in dysfunctional interaction patterns by bringing

about changes in the OP's behaviors that have complemented and,

therefore, maintained the dysfunctional interactions.

OPFT explicitly creates change at both the intrapersonal (affective and cognitive) and interpersonal levels. In OPFT, the therapist facilitates intraoersonal changes in the OP that can effect

changes in those OP behaviors that maintain dysfunctional family

interactions. (Because of the strategic orientation of HSFT, no

other intrapersonal changes are sought by the OPFT therapist.)

The therapist then facilitates or directs the OP to change these

behaviors. When the OP complies, the interaction patterns are

eventually forced to change as one "cog in the systemic wheel"

behaves differently, as the Principle of Complementarity states.

56
Intrapersonal restructuring. In David's case, the therapist began

to restructure David's introjection of the family's interaction

patterns by tracking (i.e., following and making use of) David's

reports of his parents' behavior toward him, that of alternately

babying and denigrating him. The therapist moved from the

reported interaction pattern to David's internalized complementary

behavior.

David's habitual response to his parents was to allow himself to

be dragged to the behavioral extremes that his parents expected of

him in his role of IP. During intrapersonal restructuring, David

achieved an understanding of his conflicting role behavior and desired to reach a middle ground more suitable to his stage in life,

i.e., neither child nor adult, but adolescent. He desired to feel

and behave, as well as to be treated, according to his age. Thus,

the only intrapersonal changes sought were those required to

restructure the corresponding interpersonal interactions.

Interfacing intrapersonal and interpersonal restructuring. Before

beginning interpersonal restructuring, the OP must understand how

she/he contributes to the family's interactional patterns. In

David's case, the therapist asked David to imagine himself in the

family context while the interaction is going on. Thus, David was

asked to observe, along with the therapist, an imagined family

interaction. As David observed the imagined family interaction,

he was taught by the therapist how he contributed to the interaction and how his being labeled an IP was the result of quietly

and passively accepting that role and label.

Interpersonal restructuring. Once the OP clearly understands the

complementary roles in the family, and has given up her/his desire

to play these roles, the OP has an investment in changing the

family's dysfunctional patterns; thus, the OP and the therapist

now have common goals, and they become therapeutic allies facing

the remainder of the family. The final step in the therapy is to

carry out the actual interpersonal restructuring with the aid of

the OP, and frequently through the OP.

The therapist, for example, might coach David to stand up to his

father when his father begins to denigrate him. The way in which

system change takes place is that when David changes his behavior,

in effect, he has interrupted the sequential flow of family interactions that cast him into the IP role. This is a clear example

of how OPFT differs from many other psychotherapies. It does not

stop at creating awareness. Instead it uses awareness as a tool

for redirecting the interpersonal behavior of the OP and thereby

bringing about system change.

The therapist must take care that the manner in which a son is

taught to stand up to his father tracks (follows and makes use of)

the family's structure as much as possible in order to minimize

the direct challenge to his father. In addition, in OPFT, the

therapist must rely heavily on the OP's ability to change her/his

57
own behavior and to maintain the change in the face of strong family pressure. Hence, the OPFT therapist must carefully plan and

rehearse the OP's new behavior. It is particularly important to

role-play various outcomes that could ensue from the OP's change.

Once the new role is mastered in therapy, following the

performance-based strategy described above, homework based on the

new role can be assigned. The tasks involve the OP's changing

her/his complementary role behavior in the family.

Ideally, when the OP changes, the family accommodates itself to

the change, thereby supporting the new behavior. Generally,

however, the first response to the OP's changed behavior is more

likely to be family pressure to return to its habitual interaction

patterns. The resulting confrontation will generally produce a

family crisis. This point is an ideal moment for the therapist to

request and obtain a conjoint family therapy session. During

these conjoint sessions, the therapist can verify the enactment

analogue and support the changes the OP is instigating.

In addition, a conjoint session or two provides an opportunity--

albeit a limited one--for the therapist to intervene directly in

family interaction patterns in which the OP is not complementary

(e.g., in the case of David, the therapist could intervene in the

marital relationship directly during a conjoint session).

However, in one or two family sessions, it is not likely that

major structural changes in these other family dysfunctional

patterns can be achieved. Therefore, only those aspects of these

"other" dysfunctional interactions that affect the OP are strategically targeted for change.

RESEARCH ON OPFT

The therapeutic techniques discussed above were developed as part

of a research program with adolescent drug abusers. This section

will briefly discuss some of this research. More detailed results

can be found in Szapocznik et al. (1983a, 1983b, and in

preparation-b).

Research Design

When the families presented themselves for treatment, they were

randomly assigned to either OPFT or to conjoint family therapy

(CFT), in which the entire family was seen by the therapist. In

OPFT, therapists were limited to a maximum of two conjoint family

therapy sessions and in CFT to a maximum of two one-person therapy

sessions. Both therapy modalities aimed to have a maximum of 12

therapy sessions, with 15 sessions the absolute maximum and 4 the

absolute minimum. Of the 72 Hispanic families included in the

study, 35 received OPFT and 37 received CFT. The subject families

were given a battery of instruments that examined functioning from

several perspectives. The instruments included measures of family

structure (Structural Family System Ratings) and climate (Family

Environment Scale), IP psychiatric functioning (Psychiatric Status

58
Schedule), parental reports of IP behavioral problems (Behavior

Problem Checklist), and IP drug abuse (Psychiatric Status Schedule

and Client-Oriented Data Acquisition Process). These instruments

were administered at intake, at therapy termination, and at a

followup administered between 6 and 12 months after therapy termination (N=52 at followup). Data were analyzed using repeated

measures, Analysis of Variance (ANOVA) primarily.

Study Population

All the families who participated in this study were Hispanic; 82

percent were Cuban-American. They were typically middle- to

lower-class, as assessed by Hollinshead's Index of Social Position

(8 percent Class I and II combined, 30 percent Class III, 34

percent Class IV, 28 percent Class V). The mean family size was

4.6, and in almost 70 percent both parents lived at home. They

averaged 15 years in the United States.

Most of the drug-abusing adolescents were male (73.6 percent male,

25.4 female), and they averaged 17 years of age. Half of the IPs

were still in school. Thirty-two percent of the IPs had been

arrested at least once; two IPs (3 percent) had been arrested

three or more times.

Most of the adolescents in this project abused multiple

substances. Marijuana, however, was clearly the most pervasive

substance they used, with 95.8 percent indicating at least some

marijuana use. Moreover, half (50.0 percent) of the adolescents

used it at least daily. The next most often used drugs in this

sample were barbiturates and other sedatives, and cocaine. The

proportion of adolescents who abused alcohol (6.9 percent) and

amphetamines (1.4 percent) was surprisingly low. The average

length of drug use in this sample was 2.7 years.

The number of daily marijuana users makes this sample unusual.

Since basic knowledge of such users is relatively scarce, comparisons were made between those who were daily marijuana users and

other drug users in the sample. Beyond behavioral variables

directly related to their heavy marijuana use, such as amount of

drug use and socialized delinquent behavior, however, the daily

marijuana users had surprisingly few differences from the other

drug users in our sample.

Research Findings

While space does not permit a full exposition of all findings,

table 1 details some of the results typical of this study. As

indicated by the F-ratios in the column labeled "Time," there was

significant improvement on almost all the clinical measures, and

this improvement was maintained at the 6- to 12-month followup.

59
TABLE 1. Means, standard deviations, and F-ratios for Phase I and II: pre-, post-, and

followup scores on Behavioral Problems Checklist (BPC), Psychiatric Status Schedule

(PSS), and Structural Family Systems Rating (SFSR)

Variable Pre

Mean (Standard Deviation) F-Ratio

CFT OPFT

Treat.

Post Followup Pre Post Followup Treat. Time x Time

BPC

Conduct problems

Personality

Inadequate

development

Socialized

delinquency

PSS

Total

Subject distress

Behavioral 43.3

disturbance (6.16)

Impulse control 64.8

(1O.15)

Reality testing

Drug abuse

9.5

(3.90)

6.8

(3.12)

3.9

(1.88)

1.9

(1.49)

43.8

(9.27)

39.9

(12.94)

45.9

(3.66)

68.2

(10.55)

7.1

(4.51)

(3.35)

1.8

(1.64)

.9

(0.74)

36.9

(6.02)

36.2

(5.79)

43.4

(4.47)

53.1

(9.05)

45.3

(3.06)

55.1

(11.25)

6.6

(4.12)

4.3

(2.95)

2.4

(2.151

.9

(1.11)

42.2

(8.80)

36.9

(6.82)

50.9

(12.72)

56.2

(12.99)

47.6

(4.59)

57.1

(12.00)

8.9

(3.98)

6.0

(3.26)

4.2

(1.83)

2.7

(1.51)

44.4

(9.81)

40.0

(9.84)

44.4

(6.36)

65.6

(10.90)

46.6

(5.41)

70.1

(12.13)

5.5

(4.14)

3.8

(3.68)

2.5

(2.08)

1.5

(1.42)

35.0

(5.36)

34.1

(3.96)

42.4

(3.43)

52.1

(9.23)

45.2

(2.45)

54.0

(8.69)

4.8

(4.22)

3.0

(3.61)

2.1

(1.69)

1.1

(1.60)

35.3

(5.36)

33.9

(3.97)

43.5

(4.16)

51.2

(8.26)

46.3

(4.47)

53.6

(1O.59)

1.92

.67

.25

2.58

3.60

1.20

3.64

.63

.07

.12

14.57c

20.44c

23.35c

17.20c

14.35c

6.79b

6.09b

28.86d

2.22

45.01c

.44

.85

1.42

.67

3.09a

.57

5.82b

1.29

.88

1.23
TABLE 1 (Continued)

Variable Pre

Mean (Standard Deviation) F-Ratio

CFT OPFT

Treat.

Post Followup Pre Post Followup Treat. Time x Time

SFSR

structure 1.5 2.3 2.9 1.4 2.8 3.4 2.15 36.64c

1.1O

(0.71) (1.10) (0.82) (0.72) (1.27) (1.12)

Flexibility 1.5 1.9 2.7 1.7 2. 1 3.2 2.21 31.56c

.40

(0.51) (0.92) (0.98) (0.57) (1.08) 0.98

Resonance 1.6 2.4 2.9 1.7 2.7 3.3 1.49 37.50c

.77

(0.78) (0.50) (0.78) (0.87) (1.15) (0.93)

Developmental stage 2. 1 2.7 3.3 1.7 3.1 3.6 .30 34.35c

2.08

(0.96) (1.04) (1.10) (0.81) (1.08) (0.94)

Iphood 2.1 2.7 (3.0) 1.8 2.8 3.0 .11 10.82C .29

(1.19) (1.31) (1.06) (0.85) (1.16) (0.90)

Conflict resolution 2.4 2.6 2.9 2.4

(0.70) (1.99)

3.1 3.4 2.17 5.87b

.63

(1.16) (1.21) (1.29) (1.27)

Total 11.1 14.6 17.7 10.7 16.5 20.0 1.61 49.25c

1.52

(2.96) (3.98) (4.63) (2.73) (5.51) (4.92)
In particular, as shown in the row labeled "Drug Abuse," there was

important reduction in overall drug use (p < .OOl). As a more

specific example, 50 percent of the sample used marijuana at least

once a day at intake, but only 5.6 percent used it that often at

termination and at followup (sign test Z=5.32, p < .OOl for each).

Thus, both BSFT modalities effectively created positive changes in

both individual and family functioning.

Comparison of OPFT with CFT in table 1 indicates that both treatments generally were equally effective in reducing overall psychopathology and substance abuse in particular. For example, in CFT

80.0 percent showed reduced marijuana use, 17.5 percent stayed the

same, and 2.5 percent got worse. In OPFT, on the other hand, 87.8

percent showed reduced marijuana use, 9.8 percent stayed the same,

and 2.4 percent got worse [X2(2)=0.64, p=.42, for the comparison

intake to termination change between CFT and OPFT, and

X

2

(2)=0.17, p=.68 for the termination-to-followup change]. Therefore, OPFT is at least as effective as CFT in reducing drug abuse

among Hispanic adolescents.

That OPFT was as effective as CFT in improving family structure

should be mentioned. Examination of the six scales and total

score of the Structural Family Systems Rating (the measures of

healthy family structure) in table 1 shows that there were no

differences between conditions that approached significance [for

examole. as shown in table 1 for the total score F(2.78)=1.52.

p=.23]. In the past, structural family therapists have operated

under the assumption that the entire family must be present during

therapy for changes in the family structure to occur. OPFT's

success indicates that this assumption is incorrect. Thus, while

we believe that changes in family structure are necessary in order

to efficiently and permanently correct IP drug abuse, these

results affirm our belief that therapists can strategically work

with only one family member to achieve structural changes in the

family system.

While CFT and OPFT tended to be equally effective therapeutically,

they tended to have slightly different numbers of therapy

sessions. OPFT clients averaged more therapy sessions [11 for

OPFT, 9 for CFT, F(1,64)=3.7, p=.O59]. A significant chi-square

[X2(2)=9.1, p < .O1] reveals that this resulted from the tendency

for OPFT cases to complete treatment within the preferred 8- to

12-session range, rather than requiring extra therapy. In fact,

fewer OPFT clients required more than 12 sessions of therapy (8

percent had 13 or more sessions in OPFT vs. 23 percent in CFT).

Thus, there was a significant tendency for CFT to have greater

variability in the number of therapy sessions.

A major problem in treating drug abuse is that of initially

engaging clients for treatment. This problem became very evident

to us during the BSFT project. Of more than 650 callers who

passed our initial telephone screening, only about 15 percent

entered therapy. On the other hand, it should be noted that 60

62
percent of those who began intake completed therapy, and 72

percent of those completing therapy were available for followup.

Thus, although we experienced difficulty in engaging families who

called and appeared to be appropriate for the study, those who

were engaged had a good rate of retention in both BSFT modalities.

FUTURE RESEARCH

About 85 percent of the adolescent drug-abusing population who

contacted our center could not be helped because they never

entered therapy. Typically, one concerned family member would

contact the center but would be unable to convince the rest of the

family to enter therapy. We believe that the BSFT framework and

OPFT technology developed by this project as tools for therapy

could also be used in the engagement process. In this case the

goal would not be amelioration of drug abuse; it would be to

effectively aid the concerned family member in getting the entire

family to enter the therapy process. Work has already begun on a

study examining this possibility (Brief Strategic Family Therapy:

A Structural Systems Approach to Engagement, NIDA Grant No. DA

03224-05; 1983 to 1985).

In the research study reported here, therapists were generally

required to use the identified patient as the OP. Even in those

cases in which a choice was allowed, the identified patient was

generally chosen as the OP. Thus, very little is known about

working with an OP who is not also the identified patient.

Another research possibility concerns the need to maintain allegiance solely with the OP in OPFT. Although we have no data on

this point, it is now our belief that maintaining alliances with

only one OP throughout OPFT may not be as critical as was first

thought. If switching alliances is permitted in OPFT, then the

therapist would be able to successfully deal with more issues

during sessions with the whole family (e.g., issues not involving

the IP), and the therapist would be able to switch from one' OP to

another at strategic times during the course of therapy. These

ideas are speculative but warrant further investigation.

Another question that remains for future research is the degree to

which the findings reported here can be generalized to other cultural populations, age ranges, and types of drug abuse (e.g.,

opiate addicts were excluded from this sample). An additional

question of generalizability comes from the research requirement

that all families, regardless of which condition they were

assigned to, had to agree to be available for conjoint family

therapy. This requirement was necessary to permit random assignment to condition. Nevertheless, whether or not this requirement

influenced the efficacy of OPFT in either direction has yet to be

established.

Another matter for future research concerns those clients who had

a relapse between termination and followup. It is possible that a

63
very few, spaced followup therapy sessions after regular therapy

termination would prevent such relapses. However, the exact

nature and timing of these followup therapy sessions, as well as

their efficacy and the identification of clients needing them,

remain to he determined.

Finally, the use of CFT and OPFT in clinical practice should be

mentioned. From the data and experience of this study, OPFT would

be preferred over CFT if there is particular difficulty in

scheduling the entire family for therapy, if one family member

requires a great deal of strengthening, or if the family is highly

disengaged. Our strongest suggestion, however, is to combine both

modalities. In this research study, strict controls were followed

to keep the two modalities as pure and separate as possible in

order to discover their differences and respective strengths.

Nevertheless, in a more typical clinical situation, combining the

two modalities would be the most powerful treatment strategy.

Thus, in most situations, a combination of OPFT and CFT modalities

is suggested as the treatment of choice.

SUMMARY AND CONCLUSION

The One-Person Family Therapy approach to the treatment of drug

abuse described here is based on the Brief Strategic Family

Therapy conceptual framework. It represents an innovative integration of family therapy techniques that have proven effective in

working with entire families and techniques specifically designed

for use with one family member. OPFT appears to be as effective

as conjoint family therapy with adolescent drug abusers and their

families. It thus provides skilled family therapists (generally

master's-level social workers and psychologists with training and

experience in structural family therapy) with a novel and useful

tool for carrying out family therapy, while minimizing the problem

of retaining entire families in therapy. Further work should

concentrate on improving our ability to engage families of drugabusing adolescents in the therapy process, generalizing results

to other types of samples, learning more about using an OP who is

not also the identified patient, exploring the possibility of

switching OPs, exploring the use of spaced followup therapy, and

integrating OPFT and CFT sessions more fully. However, it is

clear that OPFT is a practical, cost-effective, field-oriented

intervention for use with drug-abusing adolescents.

REFERENCES

Coleman, S.R., and Davis, D.E. Family therapy and drug abuse: A

national survey. Fam Process 17(1):21-29, 1978.

Frankel, L. Structural family therapy for the chemically

dependent woman. Unpublished manuscript, 1984.

Haley, J. Problem-solving Therapy. San Francisco: Jossey-Bass,

1976. 275 PP.

Madanes, D.

Bass, 1981.

Strategic Family Therapy. San Francisco: Jossey64
McGee, T.F., and Williams, M. Time-limited and time-unlimited

group psychotherapy: A comparison with schizophrenic patients.

Comp Group Stud 2:71-84, 1971.

Minuchin, S. Families and Family Therapy. Cambridge: Harvard

University Press, 1974. 268 pp.

Minuchin, S., and Fishman H.C. Family Therapy Techniques

Cambridge: Harvard University Press, 1981. 303 pp.

Muench. G.A. An investiqation of the efficacy of time-limited

psychotherapy.

Stanton, M.D.

J Counsel Psycho1 12:294-298, 1965.

Family treatment approaches to drug abuse problems:

A review, Fam Process 18:251-280, 1979.

Stanton, M.D.,nd T.C. Engaging "resistant" families in

treatment: II. Principles and techniques in recruitment. Fam

Process 20:261-293, 1981.

Szapocznik, J.; Foote, F.H.; Perez-Vidal, A.; Hervis, O., and

Frankel, L. Manual for One Person Family Therapy. In

preparation-a.

Szapocznik, J.; Hervis, 0.; Kurtines, W.M.; and Spencer, F. One

person family therapy. In: Lubin, B., and O'Connor, W.A., eds.

Ecological Models: Application to Clinical and Community

Health: New York: John Wiley and Sons, Inc., 1984.

Szapocznlk, J.; Kurtines, W.M.; Foote, F.H.; Perez-Vidal, A., and

Hervis, 0. Conjoint versus one person family therapy: Further

evidence on the effectiveness of family therapy through one

person. In preparation-b.

Szapocznik, J.; Kurtines, W.M.; Foote, F.H.; Perez-Vidal, A.; and

Hervis, 0. Conjoint versus one person family therapy through

one person. J Consult Clin Psychol 51:881-889 1983a.

Szapocznik, J.; Perez-Vidal, A.; Hervis, O . Foote F.H . and

Spencer, F. Brief Strategic Family Therapy: A Final Report.

NIDA Technical Report, 1983b. 88pp.

AUTHORS

Franklin H. Foote, Ph.D.

Jose Szapocznik, Ph.D.

William M. Kurtines, Ph.D.

Angel Perez-Vidal, A.C.S.W., Ph.D.

Olga K. Hervis, A.C.S.W.

University of Miami

Miami World Health Organization Collaborating Center

for Mental Health, Alcohol and Drug Dependence

Spanish Family Guidance Center

Department of Psychiatry, School of Medicine

747 Ponce de Leon Blvd., Suite 303

Coral Gables, FL 33134

65

PERSONALIZED NURSING: AN

EFFECTIVE INTERVENTION MODEL

FOR USE WITH DRUG-DEPENDENT

WOMEN IN AN EMERGENCY ROOM

Marcia D. Andersen

INTRODUCTION

This paper will describe a study evaluating a nursing intervention

model known as Personalized Nursing with a group of treatmentresistant drug-dependent women. Subjects were drug-abusing women

who entered the emergency room (ER) in Detroit, Michigan, with

health problems; some of these were related to their drug abuse

and some were not. Women who refused referral to traditional drug

treatment programs available in the community were asked to

participate in the study. Women participating in the study were

randomly assigned to Personalized Nursing intervention or to no

treatment. The Personalized Nursing intervention consisted of

home visits to these women by project nurses. The focus of these

visits was on developing a sense of well-being and life control.

Well-being was defined as a person's sense of contentment, health,

happiness, and satisfaction with current life. Life control

existed when a patient identified the problems she wanted to work

on and perceived herself as involved in directing changes in her

life. The program was limited to 8 weeks.

It was hypothesized that daily drug use would decrease as the

sense of well-being increased for women in the experimental group.

Further, it was expected that the women's perceived stress would

also decrease.

One hundred fifty-five women were interviewed in the hospital

emergency room over a 2-year period by project nurses. Approximately half of the women (72) were randomly assigned to the

Personalized Nursing intervention (the experimental treatment).

The experimental group received home visits by project nurses once

a week for a maximum of 8 weeks. For ethical and practical

reasons, the 83 subjects in the comparison group were given

Personalized Nursing intervention only in the ER. They did not

have home visits by project nurses. During the pilot study, it

became evident that a subset of the experimental treatment group

wanted to have members of their social network treated also.

67
Because the specific focus of this study was to examine needs of

drug-dependent women, male social network members were not

included. However, female social network members were treated by

the project nurses in conjunction with that subset of experimental

women who voluntarily requested that their friends be offered

treatment. Fifty-four women who were friends or relatives of

women in the experimental group were also treated as part of this

study.

This paper describes the background for the study, the theoretical

framework of the intervention model, the research methods used,

and the results. Suggestions for further research based on the

results of this study are then presented.

BACKGROUND

Women's Treatment Needs

As research substantiates early anecdotal reports, it has become

clear that drug-dependent women's treatment needs differ from

those of drug-dependent men (Andersen 1980a, Beschner et al. 1978,

Burt et al. 1979. Tucker 1981. Colten 1981. Reed and Moise 1979.

Ryan 1981, Schultz 1975). It is well documented that drug- .

addicted women have many serious medical problems, and they are

more likely than men to cite physical problems as the reason for

entering treatment (Andersen 1980a, 1980b, 198Oc, 1982; Beschner

and Thompson 1981, Cuskey 1982). Hall et al. (1981) and Dammann

and Ousley (1978) report that drug-dependent women have lower

self-esteem and fewer social supports, and are more likely to be

responsible for the care of dependent children than men. They

also found, as did Moise et al. (1982), that women were less

likely than men to be employed, more likely to be receiving

welfare, and more dependent on others.

Use of Emergency Rooms

The use of hospital emergency rooms by drug-dependent women

continues to be an issue of considerable social, medical, and

economic concern (Shrader et al. 1982). Data from both the Drug

Abuse Warning Network (DAWN 1975 and 1976, 1982) and the Client

Oriented Data Acquisition Process (CODAP) suggest that drugdependent women are more likely to require hospital emergency room

treatment than drug-dependent men are (Burt et al. 1979).

Women who come to emergency rooms are less likely than men to want

or accept a referral to a traditional drug treatment program for

help with their substance abuse problem (Andersen 1980a, 1982;

Reed et al. 1981). Drug-dependent women are likely to have

dependent children at home and thus are less able to take advantage of traditional treatment programs if child care is not

provided. Boyd and Mast (1983) also suggest that the drug use of

many women is related to the drug use of the men in their lives.

68
These women may feel unable to change their lifestyle because the

men in their lives are using or trafficking in drugs.

The ER visit for a drug or drug-related problem generally indicates serious problems in a woman's life, in addition to the

immediate health problem for which she has requested help from the

ER staff. However, hospital emergency rooms are not designed to

provide ongoing treatment or continuity of care for chronic health

problems. The heavy client flow in most emergency rooms makes it

impossible for the staff to provide comprehensive health care for

the drug-dependent woman or for them to follow up to make sure

that she gets the services needed. When drug abuse is diagnosed,

some attempt is usually made to refer the woman to a drug treatment program outside the hospital. Unfortunately, there is rarely

any attempt to follow up, and most addicted women do not enter a

formal treatment program after being treated for a crisis in an

emergency room.

In spite of the documented need for treatment services oriented to

these women, few programs have been established (Beschner and

Thompson 1981, Andersen 1980a, Cuskey 1982, Reed et al. 1981).

Multiple factors contribute to problems in women's health care and

problems related to substance abuse, and a more flexible mode of

intervention is needed than what is currently available. There is

evidence that thousands of drug-dependent women are treated in a

hospital emergency room each year. Yet there is little evidence

that their needs are being met within the traditional health care

system.

Nurses are a potential resource of health care personnel for such

an intervention. Nursing is concerned with the total health needs

of individuals and has long recognized the interaction between the

person and the environment. Nursing has a history of providing

health care in homes and a variety of settings.

Theoretical Foundation of the Personalized Nursing Intervention

Model

Personalized Nursing is an intervention model theoretically based

on the concept of well-being and the capacity to direct one's own

life; it uses the traditional nursing process in a unique fashion

in order to assist people to get the help they need and increase

their sense of well-being. Nurses develop an understanding of the

client's point of view with respect to each step in the nursing

process (i.e., assessment, development of a list of focal concerns, goal development, intervention, and evaluation). Nurses

assist clients to identify areas of stress related to health, drug

use, and other spheres of life. The nurses focus on helping

clients identify the different options for addressing concerns

directly. Nurses encourage clients to plan for both anticipated

and unanticipated changes rather than just reacting when changes

occur. As health care providers, nurses are in a unique position

because, unlike social workers, psychologists, or drug counselors,

69
they can assist drug-dependent individuals to resolve both health

and social problems.

Sample Selection

The 155 subjects in this study were drug-dependent women who presented for health care at a large urban hospital emergency room

(Detroit Receiving Hospital, Detroit, Michigan). These women were

18 years or older and were admitted to the emergency room with

physical or emotional complaints or both. ER staff members

referred women to project nurses present in the ER. Their presenting health care problems were sometimes related to their drug

dependence and sometimes not. Women referred to this study were

drug-dependent and had refused referral to traditional treatment

programs; in this sense they represented a reluctant treatment

group. During the study it became evident that most of these

women had had other drug treatment experiences and chose not to

repeat those experiences.

Design

The study was experimental in nature, with a pretest-posttest

control group design (Campbell and Stanley 1963). The variables

examined in the study were daily drug cost and perceived stress.

Consent was obtained for study participation, and clients were

randomly assigned to the control or experimental group. Both

groups were interviewed three times: at a pretest session, at an

8-week posttest session, and at a 6-month followup session. The

Personalized Nursing Interaction Model was used with the experimental group for a maximum of 8 weekly 1-hour sessions, usually

conducted in the client's home. The control group had no weekly

sessions with the nurse. However, for ethical reasons, the

control group did receive personalized nursing counseling by

project nurses when they were in the ER and referral to community

agencies for identified concerns.

Fifty-four female drug-using friends and relatives of a subset

(N=12) of experimental clients were also treated; they were called

social network clients. Since subjects often used drugs in

groups, clients expressed a desire to have these "network" friends

or relatives included during the nurse's visit. Network members

were not study subjects per se. In the study results, experimental clients who voluntarily referred networks were analyzed

both separately and together with other clients in the experimental group who had not voluntarily referred network members.

Results will be reported separately when appropriate. There were

no pretest differences between network and nonnetwork groups.

MEASUREMENT OF STUDY VARIABLES

Daily drug cost and perceived stress were the two dependent variables in this study. Drug use was measured by calculating the sum

of the street cost or usual cost of each reported substance. If

70
the client received drugs free, the expected cost was calculated.

Stress, defined as people's sense of upset with any or all spheres

of their lives, was conceptualized from the client's perspective.

The specific measures used to measure stress are discussed in

detail in a later section of this paper,

Several methods of assessing the client's concerns and perceived

stress were used, including the Ireton Personal Inventory and a

well-being journal. The Inventory (Ireton 1979, 1980). developed

as an assessment tool for use in a family practice setting,

assesses an individual's perceptions of concerns in a variety of

life spheres (i.e., work, marriage, school, health, sexuality,

general stress, ability to cope, emotional support, and so forth).

On a Likert-type scale from 1-9, subjects indicate their concern

or worry in each sphere of life. The Inventory is divided into

three parts: 1) concerns about stress and mood in general and

specific work/family concerns, 2) self-perceptions of one's personality, i.e., self-confidence, and 3) open-ended questions to

identify specific concerns and worries.

In this study, the items within the emotional distress factor were

used to measure stress, including feeling irritated or angry, confused or overwhelmed, unhappy or depressed, pressured or stressed,

and worried or anxious. The items were examined separately and

the scores summed to create a factor score for emotional distress.

Validity analysis was also done as part of this study. Several

tests of concurrent validity of the scale were conducted. Scores

on the Ireton Personal Inventory were compared with scores on the

Heimler Scale of Social Functioning (Heimler 1967, 1975) and the

Social Readjustment Rating Scale (SRRS) (Holmes and Rahe 1967). A

significant correlation of 0.53 (P=.OOO1) was found between the

negative mean on the Heimler Scale of Social Functioning and the

Ireton emotional distress factor score, and a significant correlation of 0.27 (p=.OOO1) was found between the number of life

changes as measured on the SRRS and the Ireton Personal Inventory.

Drug Use Measures

Drug cost was used as a measure of drug use in an attempt to

account for the wide variety of drugs used by subjects. Polydrug

abuse was the norm in the Detroit study subjects. It would have

been difficult to measure change if only drug use were measured

because 1) qualitative urine screens (i.e., urine tests measuring

the amount of each drug taken in addition to naming the drugs in

the urine) were prohibitively costly, and 2) if one drug

decreased, another similar drug might increase. Drug cost was

thought to be a measure of severity of drug use in general because

heroin, pentazocine (Talwin) and pyrabenzamine (Ts and Blues),

cocaine, and hydromorphone hydrochloride (Dilaudid) cost more than

codeine, acetaminophen (Tylenol), and diazepam (Valium). While

all drug use is of concern, a decrease in overall use was the goal

of this study.

71
Drug cost was measured by summing all the reported costs for drugs

and alcohol in the week before the interview and dividing the

total weekly cost by seven to obtain a daily drug cost. The

validity of the subject's report of daily drug cost was spotchecked by comparing it with the amount of drugs shown on

urinalysis. The correlation between the client's report and the

number of drugs found in her urine was very strong (r=.93;

p=.0001). The reported drug cost was checked with a street drug

price list developed by project staff from interviews with clients

and clients' family members. The list was regularly updated by

all project nurses as new information became available. Since

clients were accurately reporting the number of drugs, and the

costs they reported were verified with street drug prices, the

daily cost figure is assumed to be valid.

Number of days clean (free) of any drug use was also assessed.

Subjects were asked to estimate the number of drug- and alcoholfree days in the 8 weeks before the posttest interview session and

in the 6 months prior to the followup interview session. Nurses'

observations were consistent with the subjects' self-reports--as

the number of reported drug-free days increased, the household

environment appeared improved to the nurse at the time of the

weekly home visits (the house was generally cleaner, the children

were dressed and in school, and so forth).

Identification of focal concerns. After the assessment process,

the client and the nurse identified the focal concerns for which

the client desired the nurse's assistance, and a list of these was

developed. The focal concerns included 1) the items the client

listed as things she was worried about and wanted to change on the

Ireton scale, and 2) activities or situations noted in a "wellbeing journal" in which the client desired assistance to effect

change. For the latter, clients were given a notebook and a pen

and asked to maintain a three-column journal related to their

activities and how they felt. In the first column they recorded

the date and time of the journal entry. In the middle and widest

column on the page, they recorded their activities, moods, medications interactions with others, food, and whatever else they were

experiencing and wanted to note. In the final column, they

recorded a number based on their sense of well-being on a scale

from 1 to 10, where 1 was very poor and 10 was the maximum possible perceived well-being. The journals began to show the nurses

and the clients how factors in their internal or external environment were related to their sense of well-being. Even clients whom

one might not have expected to keep a diary generally would record

at least 1 or 2 days of activities and associated well-being

scores if they were given a notebook and a pen.

Goal development. Long- and short-term goals related to each

concern were established by the client and the nurse. Goals were

considered to be short term if they could be expected to be accomplished in the next week and long term if they could be expected

to be attained by the end of 8 weeks. This period was chosen

72
because it seemed to allow resolution of some of the immediate

crises that women reported during ER visits.

Interventions. After the development of a list of focal concerns

and goals related to each issue on the list, the client and the

nurse met weekly in the client's home. Reassessment, replanning,

and intervention phases continued until the client perceived that

an acceptable state of well-being had been achieved. The interventions were specific and personalized in order to ensure that

the goals are obtained. The nurse and client had to be creative

in developing intervention strategies and in personalizing them

according to the client's life situation.

Examples of interventions included:

1) home nursing care, such as soaking and dressing of

skin abscesses

2) family communication counseling

3) providing appropriate reading material to the

client to facilitate goal attainment, for use

between visits with the nurse

4) referral to high school completion courses

5) referral to Health Department for birth certificate

to facilitate getting identification needed for

application for General Assistance

Evaluation. At the end of 8 weeks, the nurse and client evaluated

their progress and the Ireton Personal Inventory was retaken.

Progress toward decreasing concern about the initial issues was

then measured. The client could then be guided into a self-help

group or an aftercare group that met on a less frequent basis,

which would continue to support the woman's efforts at restructuring her life and maintaining or increasing perceived well-being.

Analysis Methods

Initial differences between the control and experimental groups

were examined using Chi-square for categorical variables (i.e.,

race) and Student's t-test for interval variables (i.e., age). In

the cases where the T-test assumption of homogeneity of variance

was violated, a Mann-Whitney U test was performed because it does

not assume homogeneity of variance.

Analysis of covariance (ANCOVA) was computed for all posttest and

6-month measures instead of the Student's t test or the MannWhitney U in cases where pretest measures were available and where

they correlated with the posttest measures. Analysis of covariance was used to partial out the variance in the dependent variables that resulted from pretest scores in cases where the two

73
scores were significantly correlated and the assumptions underlying analysis of covariance were not violated. The adjusted

means, F statistic, and level of significance are reported along

with the means.

A significance level of .10 was considered to be an acceptable

level of significance for this exploratory study. The results are

expected to identify trends in treatment approaches for a hard-totreat group of addicted women; therefore, a liberal alpha level is

justified. Any indications and trends that are discovered in this

exploratory work warrant further study; trends are an appropriate

outcome goal because so little is currently available for inner

city residents who are addicted and seek no assistance for their

addiction.

RESULTS

It was hypothesized that interaction with the Personalized Nursing

Intervention Model would be associated with a decrease in daily

drug use and perceived stress. Women receiving the experimental

treatment were expected to show an improved sense of well-being.

As their sense of well-being increased, daily drug use and stress

were expected to decrease, based on the assumption that drug use

and stress are associated with a poor sense of well-being.

It was also expected that clients who brought their female friends

and relatives into the treatment program and were treated simultaneously with these social network members would change their drug

use patterns more significantly than clients who were treated

alone and those who were not treated at all.

Sample Description and Pretest Differences

As can be seen in table 1, there were no initial differences on

any demographic variables between the control and experimental

groups. Tables 2 and 3 examine drug history variables (costs and

types) between experimental and control groups. There were no

statistically significant differences between the control and

experimental study groups with respect to drug history or in types

of drugs used.

It is important to remember that the sample of women in this study

had had at least one previous drug treatment experience (66

percent) and all refused referral to known community treatment

programs. However, the main problem that both the experimental

and control group desired help on was their drug habit. Thus

while they wanted help with their drug dependency, the traditional

treatment modalities were not desired. Other areas where change

was desired were living situation, relationships, and personality

characteristics. There were no differences between experimental

and control groups in the areas they desired to change. There

were also no differences between groups on variables related to

health and stress.

74
TABLE 1. Initial demographics

Characteristics

Experimental Control Network

Group Group

(n=72)

Participants

(n=83) statistic p (n = 54)

Race

Black 86%

White 14%

Hispanic OS

Age (x) 29

Monthly income (x) $1,067.00

Partnership status

Married or livlng 16%

together

Single or 1iving 84%

separately with

no partner

11%

89%

Number of

children (x)

1.8

Number of children 1

living with client (x)

Years of education

conpleted (x)

11

10 years or fewer

II years

12 years

More than 12

Number of times

arrested (x)

83%

15%

2%

28

$1,567.00

x

2

(2)=1.78 NS 96%

4%

0%

+(148)=-1.24 NS $770.00

X

2

(1).0.63 NS 17%

83%

1.7 +(148)=0.39 NS 2.4

1 +(142)=-0.24 NS

11 +(152)=-0.89 NS

47%

14%

29%

10%

33%

32%

25%

10%

6.7 +(125)=0.57 NS

1.5

11

34%

17%

20%

21%

8.9

75
TABLE 2. Initial drug history

Characteristics

Experimental Control Network

Group Group Participants

(n=72) (n =83, Statistic p (n =54)

Daily cost of

drugs (x)

$47.00

Daily cost of

heroin (x)

$40.26

Age at first use (x) 16.5

Number of prior drug

treatment program

admissions

1.2

Number of time

periods free of drugs

since first use (x)

Number of drugs

found In urine (x)

Type of drug first

used

Heroin

Marijuana

Alcohol

Other

2.2

2

23%

48%

25%

4%

$63.00

$53.14

15.5

1.4

2.2

5

17%

46%

28%

9%

U=2411.0

+(105)=-1.56

+(127)=1.23

+(l26)=-0.35

+(108)=0.10

(72)=-1.05

NS $39.00

NS $42.00

NS 17

NS 1.1

NS 2.3

NS 2

NS 351

41%

20%

4%

X

2

(3)=1.68

76
TABLE 3. Initial drugs used

x

2

(1)=0.21

x

2

(1)=0.03

x

2

(1)=1.12

x

2

(1)=0.31

x

2

(1)=1.27

x

2

(1)=0.98

+(142)=-(0.42)

Characteristics

Experimental Control Network

Group Group Participants

(n =72) (n =83) statistic p (n =54)

Reported drug use

Heroin

Use

No use

Cocaine

Use

No use

Pentazoclne

(Talwin)

Use

No use

Marijuana

Use

No use

Diazepam

(Valium)

Use

No use

Barbiturates

use

No use

Codeine

use

No use

Amphetamine

use

No use

X

2

(1)=0.91

Number of drugs

used (x)

Usual route of

heroin use

Intravenous

Other

70%

30%

15%

85%

26%

74%

47%

53%

32%

68%

4%

96%

37%

63%

12%

88%

3.0

95%

5%

77%

23%

25%

75%

23%

77%

49%

51%

41%

59%

7%

93%

47%

53%

7%

93%

3.1

93%

7%

NS

X

2

(1))=2.26 NS

NS

NS

NS

NS

x

2

=0.31

NS

NS

NS

NS

74%

26%

8%

92%

10%

90%

46%

54%

23%

77%

2%

98%

28%

72%

6%

94%

2.6

83%

17%

Posttest Differences

Drug use. The posttest results compared all experimental subjects

with all control subjects. Control subjects were also compared to

experimental subjects who did not refer networks and to those who

did. The experimental subgroups (i.e., those with networks and

those without networks) were compared, but, since there were no

significant differences between those groups, the results are not

discussed in this paper.

Table 4 examines differences with respect to drug use between the

control and experimental group clients at the posttest and followup sessions. Experimental subjects reported a lower daily drug

cost than control subjects at 8 weeks ($14.24, SD=19 vs. $28.97,

SD=40) (F(1,95)=2.90; p=.09) Experimental subjects also reported .

a lower daily cost of eroin ($13.94, SD=23) than control subjects

($42.27, SD=47) at the 8-week posttest interview. The differences

were statistically significant (U=165; p=.O1). It is interesting

to note that the daily cost of heroin went down for the controls

77
from $42.27 at 8 weeks to $18.22 at 6 months. The experimental

group's daily cost of heroin went up from $13.94 at 8 weeks to

$30.92 at 6 months. This phenomenon will be examined in the

discussion section.

TABLE 4. Changes in drug use

8 Weeks

6 Months

Experimental Control

Group Group

(n=34) (n=66)

(n=28) (n=44) Statistic p

Daily drug cost (ii)

8 Weeks

Adjusted mean

6 Months

Adjusted mean

Daily heroin cost 

8 Weeks

6 Months

Number of days

free of drugs

8 Weeks

6 Months

Number of drugs

in urine

8 Weeks

6 Months

Change in daily

drug cost from ER

to 8 weeks

$14.24 $28.97

$16.50 $28.60

$15.21 $14.05

$16.46 $13.56

$13.94 $42.27 U=165

$30.92 $18.22 t(29)=1.46

26

39

20

34

5.8 9.5

Not enough data to

compute statistic*

t(48)=-1.32 NS

-$24.88 -826.66 t(96)=0.16 NS

F(1,95)=2.90

F(1,68)=0.44

t(83)=1.10 NS

t(60)=0.38 NS

.09

NS

.O1

NS

*Urine data were initially collected to validate the drug cost

measurement. When the validity testing was completed and showed

drug cost to be correlated with drugs in urine samples, urine

samples were no longer collected.

Stress. Table 5 shows the changes in stress-related scores at the

8-week posttest and 6-month followup. The experimental group had

less perceived stress at 8 weeks (p=.O9) and 6 months (p=.02).

They also had less anxiety (p=.04), less confusion (p=.06), and a

lower composite distress score (p =.06) at 8 weeks. There is an

implication that the trend would have continued had intervention

been prolonged. When the control group and the experimental

78
groups with networks were compared, the network group had significantly lower perceived depression (p=.03) at 8 weeks.

TABLE 5. Stress changes--experimental subjects vs. control

subjects

8 Weeks

6 Months

Experimental Control

Group Group

(n=34) (n=53)

(n=28) (n=39) Statistic p

Perceived anxiety

(1=Low; 9=High)

8 Weeks

6 Months

Perceived anger

(1=Low; 9=High)

8 Weeks

Adjusted mean

6 Months

Adjusted mean

Perceived confusion

(1=Low; 9=High)

8 Weeks

Adjusted mean

6 Months

Perceived stress

(1=Low; 9=High)

8 Weeks

Adjusted mean

6 Months

Perceived depression

(1=Low; 9=High)

8 Weeks

Adjusted mean

6 Months

Ireton composite

emotional distress

score (5=Low; 45=High)

8 Weeks

Adjusted mean

6 Months

Adjusted mean

4.2 5.5 t(85)=-2.12 .04

5.0 5.7 t (65)=-1.02 NS

3.5 4.1

3.5 4.1

3.8 4.2

3.8 4.2

3.5 4.7

5.4 6.5

4.4 4.5

5.4 6.5

5.4 6.5

5.3 6.8

4.1 5.0

4.1 5.0

4.8 5.3

20.5 25.8

20.1 25.6

23.3 26.5

23.5 26.4

F(1,85)=0.83

F(1,64)=0.38

NS

NS

F(1,85)=2.80

t(65)=-0.13

.1O

NS

F(1,84)=3.00

t(65)=-2.35

.09

.02

F(1,85)=2.60 NS

t(65)=-0.81 NS

F(1,83)=3.70

F(1,64)=1.10

.06

NS

79
Summary of Results

The study indicates that nurses can affect stress and drug use in

addicted women. At the 8-week posttest, daily drug cost and daily

heroin costs had gone down for the experimental group. However,

at the 6-month posttest, daily drug cost and daily heroin cost for

the experimental group increased, although it did not reach its

initial pre-intervention levels. The increase in drug costs at

6-month followup is probably a result of the lack of nursing

intervention after the 8-week period. Interestingly, both the

drug costs and heroin costs of the control group went down at 6

months. In other words, the control group decreased use also,

only at a slower pace. What accounted for this decrease in use by

the control group at 6 months? Several speculations are offered.

The single Personalized Nursing Intervention counseling in the ER

may have had an impact on the client. Controls who had had the

singie intervention in the ER were receptive to followup and were

easily found. (Originally the single intervention in the ER was

not part of the design. However, about 20 clients who had not had

Personalized Nursing Intervention in the ER but who just answered

the initial questionnaire were never found for followup. Because

of the followup and ethical considerations, project staff members

instituted the single ER intervention.) Another speculation is

that of "burnout," a phenomenon that can be seen in both experimental and control groups. The mean age of the total population

was 28.5, number of times arrested was 7.25, and age at first drug

use was 16. It appeared that the following factors evoked a

desire for change in these women: 1) leading a drug lifestyle for

so many years, 2) the approach of age 30, 3) entrance into adolescence of their own children, and 4) the ER episode. Personalized

Nursing Intervention could be considered a catalyst toward

lifestyle change.

Examination of daily drug cost and the Ireton emotional distress

score showed trends indicating that the experimentals with network

participation made larger gains than the control group or

experimentals without networks. Further study on the use of

client networks in treatment is indicated.

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ACKNOWLEDGMENTS

Phyllis S. Brenner contributed substantially to the literature

review and demographic description of the sample in this paper.

AUTHOR

Marcia DeCann Andersen, Ph.D., R.N., C.S.

Associate Professor

College of Nursing

Wayne State University

Detroit, MI 48202

82
BRIEF EFFECTIVE TREATMENT

STRATEGIES: PHARMACOLOGICAL

THERAPY FOR OPIATE ADDICTS

Herbert D. Kleber

INTRODUCTION

Psychopathology and drug abuse may interact in at least three

ways. Psychopathology may lead to drug abuse (e.g., attempts at

self-medication of dysphoric affect); drug abuse may lead to

psychopathology (e.g., depression related to rejection by significant others or possible neuroendocrine changes secondary to

chronic drug use); or psychopathology and drug abuse may exist

independently of each other but with interactive effects (e.g.,

schizophrenic patients may cause significant problems in treatment

programs, leading to their being rejected by the staff; depressed

patients are more likely to drop out of drug treatment programs,

while anxious patients are more likely to be retained). In a

study of heroin addicts in the community who had never sought

treatment, Kleber et al. (1981) found that the key difference between them and a treatment group was that the community group had

less psychopathology. Thus, at least for some drug abusers, the

degree of psychopathology, rather than just the substance abuse

per se, may be what led them to seek treatment in a drug program.

Even where psychopathology may have led initially to the drug

abuse, once the latter is established it is unlikely that treating

the initial pathology will eliminate the drug abuse since this has

taken on a life of its own. However, it may help the patient take

better advantage of treatment opportunities for the drug problem.

When psychological methods are inadequate to treat these problems,

it may be helpful to consider psychopharmacologic agents. In the

New Haven drug treatment program, we have set up a special program

to treat patients with serious psychopathology. The patient remains in treatment at his or her regular program but, in addition,

is seen by a therapist, usually more experienced, who can provide

more attention over a sustained period and recommend pharmacotherapy if indicated.

83
Physicians connected with drug treatment programs usually wish to

diminish a patient's reliance on drugs to solve life's problems.

Trying to stick to this belief, they find themselves on the one

hand under pressure by patients seeking drugs, especially minor

tranquilizers, and on the other hand wanting themselves to prescribe something because they believe that patients could benefit

from use of a particular agent such as an antidepressant or antipsychotic. Their problem is made more difficult by the scarcity

of controlled studies about such drugs in the treatment of narcotic addicts; the lack, until recently, of adequate tools for

accurate diagnostic assessment; the pressure of time and too many

patients; and, finally, the pressure of other staff members either

not to prescribe any other drugs or to prescribe drugs that will

solve the patient's problems in an almost magical way. Physicians

in treatment programs such as naltrexone maintenance, outpatient

drug free, or residential therapeutic communities may be even more

reluctant than those in methadone programs to use ancillary medications. In some therapeutic communities, there is no real

distinction between illicit drugs and psychiatrically indicated

medications. Finally, the presentation of psychopathology with

patients maintained on methadone or in withdrawal may be quite

different from that when the same patient is on a very low dose or

when not on methadone. At times, immediately following withdrawal, there seems to be emergence of symptomatology even where

the detoxification has been slow and stress has been minimal.

Symptoms of psychosis or mania have been observed under such

circumstances.

Psychotropic agents are most helpful to opiate addicts when used

to treat coexisting psychopathology. While there is no clear evidence that such agents will reduce or affect the addiction itself,

they may help keep patients available for rehabilitation efforts.

Concomitant severe psychopathology has been associated with poorer

outcome in treating drug abusers. Chemical approaches that could

reduce their severity could significantly improve the quality of

patients' lives.

In this presentation, I shall first describe the evidence for the

existence of a high prevalence of psychiatric disorders in addicts

that might be treatable by psychotropic medication and then review

the categories of drugs that might be of therapeutic use for such

disorders. More detail on this has been given by the author in a

recent review article (Kleber 1983).

84
PSYCHIATRIC DISORDERS IN OPIATE ADDICTS

The high prevalence of diagnosable psychiatric disorders in opiate

addicts has begun to be documented by careful studies. Most early

studies usually employed only dimensional symptom or personality

scales; a major exception is the large-scale study recently completed at Yale by Kleber et al. (1981) and Rounsaville et al.

(1982a). Psychiatric diagnosis was obtained on 533 subjects

applying for treatment at the multimodality Drug Dependence Unit

of the Connecticut Mental Health Center in New Haven, Connecticut.

Subjects in this study met Research Diagnostic Criteria for narcotic dependence. Information for making diagnostic judgments was

collected on the Schedule for Affective Disorders and Schizophrenia (SADS). On the basis of this information, the subjects

were classified according to the Research Diagnostic Criteria

(RDC), a set of operational diagnostic definitions with specific

inclusion and exclusion criteria for a variety of nosologic

groups.

Using the SADS-L, diagnoses are made for both the current time

period and for a lifetime. Depression was the most commonly diagnosed symptomatic condition; 23.8 percent of the sample were in a

current episode of major depression at this evaluation. Other

affective disorders, including minor depression (2.3 percent),

manic disorders (0 percent), and hypomanic disorders (.9 percent)

were comparatively infrequently diagnosed, as were schizophrenia

(.2 percent) and schizoaffective disorders (1.5 percent). Only

small fractions of the sample were in current episodes of panic

(.9 percent), obsessive-compulsive (1.3 percent), or generalized

anxiety (.9 percent) disorders. However, a substantial minority

had a current phobia (9.2 percent) or abused alcohol to a degree

that met the criteria for a current episode of alcoholism (13.7

percent) (table 1).

In regard to lifetime RDC diagnoses, 86.9 percent of the addicts

surveyed met the criteria for some psychiatric disorder exclusive

of drug addiction in their lifetime. The most commonly diagnosed

disorders were major depression 53.9 percent, alcoholism 34.5 percent, antisocial personality 26.5 percent, intermittent depression

18.8 percent, labile personality 16.5 percent, phobic disorder 9.6

percent, schizotypal features 8.4 percent, minor depression 8.4

percent, other psychiatric disorders 6.8 percent, hypomanic disorder 6.6 percent, and generalized anxiety disorder 5.4 percent.

85
TABLE 1. Current rates/100 of psychiatric disorders in opiate

addicts according to Research Diagnostic Criteria

Current RDC Diagnosis

Affective disorders

Major depression

Minor depression

Manic disorder

Hypomanic disorder

Schizophrenia

Schizoaffective disorders

(depressed and manic)

Number

(N=533)

127

12

0

5

1

8

Rate/100

23.8

2.3

0.0

0.9

0.2

1.5

Anxiety disorders

Panic

Obsessive-compulsive

Generalized anxiety

Phobic

5 0.9

7 1.3

5 0.9

49 9.2

Alcoholism 73 13.7

Other psychiatric disorder

Any current disorder (including

personality diagnoses)

25 4.7

375 70.3

All other disorders, including schizophrenia, schizoaffective

disorders, mania, cyclothymic personality, obsessive-compulsive

disorder, panic disorder, and Briquet's disorder were found in

fewer than 5 percent of the sample. When affective disorders are

combined, it is apparent that opiate addicts in this sample are at

high risk in that 74.3 percent met the criteria for some affective

disorder (table 2).

86
TABLE 2. Lifetime rates/100 RDC psychiatric diagnoses in addicts

by sociodemographic characteristics

Type of disorder

Percentage

(N=533)

Affective disorders

Major depression

Minor depression

Intermittent depression

Cyclothymic personality

Labile personality

Manic disorder

Hypomanic disorder

Bipolar 1 or 2

Any affective disorder

53.9

8.4

18.8

3.6

16.5

.6

6.6

5.4

74.3

Schizophrenic disorders

Schizophrenia

Schizoaffective depression

Schizoaffective manic

Anxiety disorders

Panic

Obsessive-compulsive

Generalized anxiety

Phobic

Any anxiety disorder

Alcoholism

Personality disorder

Antisocial personality

Briquet's

Schizotypal features

Other psychiatric disorders

Any lifetime disorder

.8

1.7

.4

1.3

1.9

5.4

9.6

16.1

34.5

26.5

.2

8.4

6.8

86.9

NEUROLEPTIC DRUGS TO TREAT SCHIZOPHRENIC DISORDERS

The incidence of psychosis, usually schizophrenic reactions, in

opiate addicts has been estimated from as low as 1 percent

(Vaillant 1966) to as high as 19 percent (Gerard and Kornetsky

1955). Our recent study puts the combined figure for schizophrenic and schizoaffective disorders at fewer than 2 percent.

The relation of opiate drug use to psychosis has been a mixed and

confusing picture throughout the past 200 years. Whereas some

authors saw morphine as a useful treatment for psychotic disorders

8 7
and other psychiatric problems (Carlson and Simpson 1963, Comfort

1977), others saw its chronic use as a cause of such psychosis

(Bell 1911), a view disputed by still others who could not find

such an effect (Pfeffer and Ruble 1946, Kolb 1925). The discovery

of opiate receptors and endogenous opiate-like substances has

increased our knowledge but not solved this particular problem.

Some researchers find opiate agonists to exert an antipsychotic

effect (Berger et al. 1980), while others find that, on the

contrary, antagonists have such an action (Gunne et al. 1977).

Still others find that neither agonists nor antagonists have a

consistent effect (Wickler 1952, Janowsky et al. 1977). The

similarities and differences between opioid agonists and antipsychotic agents has recently been reviewed (Clouet 1982), as has

the relationship between endorphins and psychopathology (Berger

and Barchas 1982).

While there may be disagreement on the relationship of exogenous

opiates, endogenous opiate-like substances, opiate antagonists,

and opiate receptors to the signs and symptoms of schizophrenia,

it seems that methadone alone may be insufficient to treat the

disorder as it appears in maintained patients, and for addicts in

general the use of neuroleptics to treat such symptoms appears

noncontroversial (Kaufman 1974, Chappel 1974, Ferris 1976, Kleber

and Gold 1978, Ciccone et al. 1980). No particular drug stands

out in this context; chlorpromazine, thiothexene, fluphenazine,

and haloperidol are all mentioned. For methadone maintenance

patients, lower doses of such drugs may be needed to control

psychotic symptoms (Kleber and Gold 1978, Ciccone et al. 1980),

perhaps because methadone either potentiates their effects or has

its own antipsychotic action. in general, these drugs should be

used cautiously because of the possibility of tardive dyskinesia.

Unlike some of the other categories of psychotropic drugs, these

drugs are usually not abused by addicts, and the problem more

often is getting the patients to continue them when they are

indicated. Once indicated, they may need to be continued for long

periods of time, although periodic drug-free trials should be

attempted. Schizophrenics can be so disruptive to a program and

have so much difficulty conforming their behavior to the structure

and rules that adequate medication may make the difference between

their remaining in the program and being expelled.

MINOR TRANQUILIZERS IN THE TREATMENT OF ANXIETY DISORDERS

The data from the Yale study (Rounsaville et al. 1982a) indicate

that approximately 10 percent of the opiate addicts were diagnosed

as having an anxiety disorder. It has been noted by a number of

authors that diazepam has become a popular drug of abuse among

opiate addicts and in methadone programs (Kleber and Gold 1978,

Woody et al. 1975a, Spensley 1976, Gould et al. 1977, Budd et al.

1979). The question, therefore, arises whether this use is an

attempt to treat anxiety and should be viewed as self-medication

or whether it represents rather another way of getting high.

Diazepam is said to "boost the high" experienced after methadone,

88
using 25-50 mg of the tranquilizer (Kleber and Gold 1978), or to

produce "a pleasant relaxed sensation which may be described as a

high" (Woody et al. 1975a).

Such patients are frequently noted to appear sleepy, ataxic, and

dysarthric at the methadone clinic and occasionally to have pathological rage attacks (Kleber and Gold 1978). There have been no

controlled studies reported in the literature using diazepam or

other benzodiazepines to treat anxiety in opiate addicts or methadone patients, with the exception of Sugarman et al. (1971), who

used prazepam to treat anxiety in detoxified narcotic addicts.

Although it was better than a placebo in reducing anxiety during

the first 2 weeks of treatment, by the third week there was no

longer an advantage.

Although benzodiazepines have been shown in numerous controlled

studies to be useful in treating anxiety in nonaddict patients,

the problem in this population is whether the abuse potential

outweighs the clinical usefulness. The abuse potential in methadone patients may be greater than in alcoholics (Kryspin-Exner and

Demel 1975). Under such circumstances it appears prudent to treat

anxiety by counseling, training in relaxation techniques, or

environmental manipulation rather than tranquilizers. One should

also be cautious about treating anxiety by raising methadone

dosage, often requested by patients if diazepam is refused, since

any relief so gained is often short-lived and followed soon by a

new request for a higher dose. Occasionally, when other methods

have been unsuccessful and the clinician is convinced of the

presence of a serious anxiety disorder, benzodiazepines may be

used if care is exercised. Panic anxiety is often better treated

with imipramine than a benzodiazepine. Its high incidence in this

population could be due to a compromised endogenous opiate system

unable to inhibit noradrenergic rebound hyperactivity.

Although one may make a theoretical case for less abuse potential

by benzodiazepines with slower onset of action--e.g., the

Philadelphia Veterans Administration drug program (G.E. Woody,

personal communication) has been using oxazepam for anxiety for a

number of years and feels there has been no significant abuse

problem--this point has not been adequately demonstrated in

controlled studies. Further, since most labs report only the

presence or absence of the benzodiazepine class of drugs in

routine urine screens rather than the exact drug, prescribing one

member of the class makes it difficult to monitor the use of other

members. Potential misuse is suggested by requested refill of

prescriptions earlier than due, supposedly lost prescriptions,

requests for increasing doses, and the desire for indefinite use

(Spensley 1976). It is even more clear when the patient appears

excessively sedated or ataxic. When misuse occurs, it should be

considered that the dangers of the drug have come to outweigh its

usefulness, and prescriptions should be terminated. The patient,

however, should be evaluated at that point as to the need for

possible diazepam withdrawal and the decision made about the

89
location for providing such treatment. Klein (1983) has argued

that patients likely to abuse benzodiazepine are also likely to

abuse alcohol, and therefore no new dependence is likely to be

incurred by a more liberal initial use of these agents in opiate

addicts as long as it is done prudently and halted if abuse

occurs.

TRICYCLIC ANTIDEPRESSANTS IN THE TREATMENT OF AFFECTIVE DISORDERS

A number of studies have emphasized the incidence of depression in

opiate addicts (Wieland and Sola 1970, Lehman and DeAngelis 1972,

Robins 1974, Weissman et al. 1976, Rounsaville et al. 1979, Dorus

and Senay 1980, Steer and Kotzker 1980). In the recent Yale

study, approximately 24 percent of the sample were diagnosed as

having a current major depression, and over two-thirds were noted

to have either chronic or episodic depressive disorders.

Spensley (1974) reported an uncontrolled trial of doxepin in 27

patients maintained on methadone whose target symptoms were

anxiety, depression, pseudowithdrawal, sleeplessness, and

apprehension. Of the 27, 25 (93 percent) reported beneficial

results of slight-to-marked degree.

Woody et al. (1975b) conducted a double-blind study of doxepin in

35 "mildly depressed patients" on methadone maintenance. Diagnosis of depression was made by a psychiatric interview, and a

number of depression-rating scales were also obtained. Although

the dropout rate from the study was high (only 16 were on the drug

or a placebo for longer than 4 weeks), there was statistically

significant improvement noted for the doxepin-treated subjects as

compared with the controls. Also, the doxepin patients tended to

be less likely to drop out. Improvement was found in symptoms of

depression and anxiety as well as in craving for heroin.

In order to overcome the design limitations in the Woody study, a

study was begun in New Haven in 1977 (Kleber et al. 1983). To

avoid the high Philadelphia dropout rate and also to avoid confounding results by the increasing doses of methadone and early

program adjustment, the patient was stabilized on methadone before

beginning imipramine. This latter drug was chosen instead of amitriptyline or doxepin partly because the sedating tricyclics have

been abused by drug addicts in some cities (Stimmel et al. 1978,

Cohen et al. 1978), but not all (Senay et al. 1977). Analysis of

the data from the study initially seemed not to confirm the Woody

findings in that there was no significant difference between the

drug and placebo groups. Closer examination of the data revealed

that this was due not to failure of the drug group to improve but

rather to the major improvement shown by the placebo group, which

did about as well as the doxepin patients in the Woody study

(table 3). This can illustrate the variability of the depressive

symptoms over time, the role of nonpharmacologic factors on outcome of depression, and, finally, the importance of not rushing in

to use drugs to treat depression in these patients. Two more

90
recent studies appear to lend weight to the Philadelphia group's

initial finding of benefit using doxepin: one was a replication

by them of their initial study but with design improvement (Woody

et al. 1982), and the other from Florida by Goldstein, also showing improvement with doxepin (Woody et al. 1982). The tendency of

depression present in the early stages of methadone treatment to

significantly improve over time without other pharmacologic intervention has been stressed by two recent studies, one by Dorus and

Senay (1980), and the other by Rounsaville et al. (1982b).

TABLE 3. Effects of treatment on depressive symptoms: Comparing

opiate addicts with primary depressives

Current study of

depressed addicts

stabilized on methadone

Imipramlne

Placebo hydrochloride

Week (N=23) (N=23)

Raskin total score

0 8.2 8.7

1 7.4 7.1

4 6.3 6.7

8 5.9 5.8

Primary depressives

Woody et al. 1975b

study of depressed

early methadone patients

Amitriptyline Doxepin

Placebo hydrochloride Placebo hydrochloride

(N=21) (N=20) (N=11) (N=13)

8.7 8.5

8.5 7.8

8.0 7.6

8.0 7.1

NA NA

NA NA

NA NA

NA NA

Hamilton total score

0 19.5

1 13.9

4 12.1

8 11.2

Beck total score

0 13.3

4 12.0

8 10.4

20.0 15.3 16.8 18.3 18.3

12.3 15.1 13.6 NA NA

11.2 15.2 12.5 15.1 7.1

10.1 14.3 11.4 NA NA

15.1 NA NA 9.1 9.1

10.5 NA NA 10.3 3.6

10.2 NA NA NA NA

NA Indicates not available.

The New Haven study found that although the depressive symptoms

often abated over time, those patients who were diagnosed as

having a current major or minor depressive disorder at admission

were more likely to use illicit drugs during the next 6-month

period. It may be, therefore, that a subgroup of depressed

patients could benefit from pharmacotherapy. The possibility that

different subgroups may require different treatments is strengthened by Schildkraut et al. (1976) and Meyer et al. (1978), who

found that during heroin administration only four of nine patients

showed elevated MHPG excretion.

91
There is agreement on the high incidence of current and past

affective disorders in opiate addicts and methadone-maintained

patients, and that depressed patients do not do as well in treatment and drop out in higher numbers. There is less agreement over

what to do about this finding and even less agreement as to

whether the cause is psychological, psychosocial, or biological.

Since there appears to be substantial change in depressive symptoms during the first 3-6 months on methadone without specific

pharmacotherapy, it may be best not to intervene with drug therapy

until it is seen whether spontaneous remission will occur. Tricyclic antidepressant medication should be considered for those

patients who do not improve after 3-6 months or those abusing

stimulants who may be trying to self-medicate. Once begun, antidepressant medications usually need to be continued at least 3

months and then tapered gradually over 3-6 weeks. Klein (1983)

has argued for a more liberal use of antidepressants in order to

gain more insight as to which subgroups are likely to benefit from

such drugs.

MAO INHIBITORS

The stimulant properties of monoamine oxidase (MAO) inhibitors may

have some abuse potential. Shopsin and Kline (1976) note that

"amphetamine-like effects including euphoria, hypomania..., flight

of ideas, and outward hostility can be associated with the use of

all MAO inhibitors even in the usually prescribed dosage range for

treating depression." The mechanism of action for this is not

completely clear even though it is known that these agents, like

the amphetamines, increase the available amount of norepinephrine,

dopamine, and serotonin at synapses. Because of the abuse potential and risk of serious reactions from certain medications or

tyramine-containing foods while individuals are taking MAO inhibitors, the dangers of use, in my opinion, outweigh the therapeutic

potential in a drug-abusing population, which can be notoriously

careless with drug, alcohol, and food intake. A way out of this

dilemma has been posed by Klein (1983), who suggests the possibility of using MAO-B inhibitors, such as deprenyl, which do not have

the potential for the tyramine reaction, or, more experimentally,

combining MAO inhibitors with tricvclics. which could block the

uptake of tyramine and be less likely to lead to a hypertensive

crisis. More animal research on this appears needed before human

trials should be carried out.

LITHIUM

The Yale study did not diagnose any current patients as manic but

found 0.9 percent to be hypomanic. Their lifetime rates showed

0.6 percent manic, 6.6 percent hypomanic disorder, 5.4 percent

bipolar 1 or 2, and 0.4 percent schizoaffective manic. Thus,

there may be a significant number of patients for whom lithium

might be a useful treatment or prophylactic agent.

92
Apparently Scher (1975) was the first to suggest treating narcotic

addicts with lithium. He noted that lithium given to heroin

addicts was associated with alleviation of withdrawal symptoms and

blocking of heroin's euphorogenic effect. Altamura (1975), on the

theory that drug addiction may be due to masked depression, gave

lithium to 20 detoxified opiate (mainly heroin) addicts. While a

few of the patients reported an enhanced feeling of well-being on

the drug and lessened psychological dependence, only nine patients

took the lithium for more than a few weeks. Followup in general

was poor, and the author concluded he could neither confirm or

refute his hypothesis. After 1 year, all patients were off

lithium and most were back on heroin.

Cronson and Cadden (1976) gave lithium to 11 addicts and felt that

9 had an excellent response, with 5 remaining drug-free after 2

years. Cronson et al. (1979) claimed that of 20 patients given

lithium for at least 1 month, 16 substantially benefited.

Flemenbaum (1974) hypothesized that a significant number of

depressed patients and chemically dependent ones "share a common

depressive oral personality but some express it as a clear affective disorder and some express it as parapsychiatric symptoms that

are usually conducive to sociopathy and/or chemical dependence."

He felt that lithium might, therefore, be of help in treating such

patients. Kleber and Gold (1978) noted that methadone patients

given lithium tended to ask for lower methadone doses because of

increased drowsiness and that this occurred regardless of whether

they felt they were helped by the lithium or not. These authors

gave lithium to seven patients with a history of recurrent depression on the theory that narcotics might be blocking or attenuating

the manic phase, so that the true bipolar nature of their illness

might not be apparent. Four of the seven patients noted clinical

improvement of their depressive episodes while on lithium.

Nahunek et al. (1978) reported giving lithium to 23 "analgesic

abusers' with equivocal results: 11 were defined as satisfactory

outcome, 12 as unsatisfactory. Better results were experienced

with stimulant abusers.

There are a number of theoretical possibilities relating to the

existence of undiagnosed or masked bipolar affective disorders in

opiate addicts or the existence of atypical depression which could

he helped by the use of lithium. Unfortunately, human studies to

date have been small, uncontrolled, and at best inconclusive.

Wider use of lithium in selected methadone programs might be

encouraged so as to gain more clinical experience with combining

the two modalities and to focus more clearly on the types of

patients that may be helped. Additionally, it should be tried in

naltrexone and drug-free programs. If clinical experience indicates sufficient usefulness, blind clinical trials can then be

undertaken. Since lithium appears to be an effective agent in the

treatment of the manic phase of manic-depressive illness and in

the prophylaxis of both mania and depression in nonopiate

patients, its use in opiate treatment may lead to improved

outcomes for a number of patients.

93
ALCOHOLISM AND THE USE OF DISULFIRAM

Abuse of alcohol by patients maintained on methadone has been

recognized as a serious problem since the early 1970s. Until

recently, however, there was disagreement about whether the

alcohol problems began while patients were on methadone or

preceded their entrance into the program. There has also been

confusion about the extent of the problem, since many studies

failed to provide operational definitions of such categories as

"excessive use of alcohol," "problem drinking," "alcohol abuser,"

or "alcoholism." An excellent review of these studies has been

done by Carroll et al. (1977), and they conclude that most individuals who had trouble while on a program appear to have had

previous problems with alcohol.

Alcohol abuse is associated with major physical problems such as

cirrhosis of the liver and premature death. In combination with

methadone, overdose death can occur. In one study, 60 percent of

the deaths in patients enrolled in or recently discharged from a

methadone maintenance program were alcohol-related (Gerston et al.

1977). Also, it is a major cause of administrative discharge from

such programs (25 percent in one study), and such patients often

deteriorate rapidly after leaving. To cope with these problems,

some programs send their patients to separate alcoholism treatment

units, while others try to treat them in the methadone program

itself. Both approaches appear approximately comparable in outcome (Baker et al. 1977). Also, in both approaches, disulfiram

(Antabuse) appears to be, at times, a useful treatment adjunct.

Studies by Charuvastra et al. (1976) and Tong et al. (1980) on the

combined use of methadone and disulfiram indicate that the combination appears to be a safe one.

It can be difficult, however, to get patients to use the drug on a

regular basis. Pascarelli and Eaton (1973) suggested on the basis

of the alcoholism literature that the methadone patients least

likely to succeed on disulfiram would be those under 40, with a

history of blackouts, currently depressed, and of low social

stability. They emphasize that the drug must be used as part of a

total treatment program. Gerston et al. (1977) list a comprehensive program as "a combination of supportive environments and

psychotherapy, crisis intervention, and an emphasis on control of

drinking."

Liebson et al. (1978) compared 25 alcoholic methadone-maintained

patients divided into two groups on a random basis. One group was

required to take disulfiram as a condition of getting their methadone, while the other was urged to take it but could get their

methadone regardless. The first group did substantially better

than the second in regard to drinking (2 percent of days with

drinking vs. 21 percent), and this requirement did not drive the

patients away from the methadone program. Because the ethics of

denying methadone to patients who refuse disulfiram may be questioned, the authors suggest "this approach be considered only for

94
those patients for whom all else has failed and whose alcoholism

has already resulted in a decision to terminate methadone

maintenance." Kamback (1979) has tried a similar contingency

method of disulfiram administration on 10 methadone patients and

also reports good results regarding alcohol abuse and changes in

lifestyle. He cautions, however, that methadone may ameliorate

some of the adverse consequences of the disulfiram-alcohol

reaction; therefore, a daily breathalyzer test should be used to

monitor alcohol intake. It appears overall that disulfiram can be

a useful treatment adjunct for the problem-drinking drug abuser,

but a contingency method will probably be required to ensure

compliance with such a regime.

SUMMARY

This paper has examined the possibilities of applying significant

pharmacologic help to a variety of psychiatric problems that may

accompany narcotic addiction. It has been shown that many of the

patients do have such difficulties, with affective disorders being

most common. As far as the various psychotropic drugs are

concerned, neuroleptics for schizophrenia and lithium for manic

disorders are generally agreed upon. A more extensive trial of

lithium in a variety of situations seems indicated. Minor tranquilizers for anxiety and MAO-inhibitors for depression are both

seen as problematic in this population--the former because of the

possibility of abuse, the latter because of the danger of drug

interaction associated with the addict's careless lifestyle.

Tricyclic antidepressants may clearly have a role in treating

major depression in opiate addicts on or off methadone, but the

lability of the syndrome over time with frequent spontaneous

remission argues against their routine use until it is clear that

depression has persisted 3-6 months into methadone. Disulfiram

appears to be a useful adjunct for drug abusers with serious

alcohol problems.

Psychotropic agents are most helpful to opiate addicts when used

to treat coexisting psychopathology. While there is no clear evidence that such agents will reduce or affect the addiction itself,

they may help keep patients available for rehabilitation efforts.

Failure to intervene may make treatment dropout and recidivism

more likely. Given the relative frequency of potentially treatable psychiatric disorders in these patients and the consequences

of undiagnosed and untreated conditions, it is important for

clinicians to maintain a high index of suspicion for concomitant

psychiatric illness and for programs to have a mechanism for

routinely diagnosing either all patients or, at a minimum, all

patients not doing well. If programs used a standard instrument

such as the SADS, it would be possible to compare various programs

on this factor; in addition, it would provide a rich source of

data for outcome studies.

95
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1982.

AUTHOR

Herbert D. Kleber, M.D.

Professor of Psychiatry

Yale University School

of Medicine

and

Director, Substance Abuse

Treatment Unit

Connecticut Mental Health Center

34 Park Street

New Haven, CT 06511

99

MEDICAL MAINTENANCE

FEASIBILITY STUDY

Don C. Des Jarlais, Herman Joseph,

Vincent P. Dole, Marie E. Nyswander

INTRODUCTION

Background

Since 1964, methadone maintenance has evolved from a small research project into the largest single modality for the treatment

of heroin addiction (Des Jarlais and Uppal 1980, Dole and

Nyswander 1976, Lowinson 1981). This evolution has been shaped by

a number of factors, including the large numbers of persons seeking methadone treatment, the need for a wide variety of rehabilitation services in addition to treatment for heroin addiction,

and a concern about diversion of the medication to persons not

officially enrolled in treatment. The current method for the

delivery of methadone maintenance treatment is within a formal

clinic setting. Such clinics are officially licensed by Federal,

State, and city governments, with explicit regulations concerning

dosages to be prescribed, frequency of patient visits to the

clinic, and use of supportive services.

The formally organized clinic may be the best method of providing

methadone maintenance to large numbers of patients at a relatively

low cost per patient, but it is possible to identify patients who

might be better served in a setting more similar to treatment of

other chronic diseases. This medical maintenance research is a

feasibility study of delivering methadone maintenance treatment in

a setting outside of clinics as they are currently organized and

regulated.

The patients who are least well served within the present organizational setting of methadone clinics tend to be the "wellrehabilitated" patients, who no longer need supportive services.

Such patients have established stable lifestyles; are generally

employed, students, or homemakers; do not abuse nonnarcotic drugs

or alcohol; and do not have the social ties with illicit narcotic

users that promote diversion.

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Requiring such well-rehabilitated patients to use supportive

services is an unnecessary expense, and it is often seen as demeaning and stigmatizing. Frequent required visits to the clinic

to pick up medication add to treatment costs, can severely limit

personal and business travel, and can threaten the confidential

nature of treatment. Compromising patient confidentiality can

lead to loss of employment and social ostracism (NY State 1983).

A final area in which treatment for well-rehabilitated patients is

undermined concerns the clinician-patient relationship. A therapeutic clinician-patient relationship requires that the patient

believe the clinician is using his or her expertise in the best

interests of the individual patient. Within the current organizational framework, well-rehabilitated patients (and others) often

perceive clinical decisions as being made to conform to impersonal

regulations rather than to the individual patient's best interest.

Clinicians, of course, also frequently see clinical decisions as

determined by impersonal regulations, thus further undermining the

clinician-patient relationship.

The present form of service delivery for well-rehabilitated

patients thus not only involves extra expense and inconveniences,

but also can be counterproductive.

Medical Maintenance

The basic concept in medical maintenance is to provide drug maintenance treatment for heroin addiction in a manner similar to

chemotherapy for other chronic illnesses, e.g., epilepsy.

Patients participating in the feasibility study are those for whom

narcotic addiction is primarily a biophysical problem rather than

a psychological or sociological problem. One of the purposes of

the feasibility study is to refine appropriate criteria and selection procedures for medical maintenance patients. The following

minimum criteria were used for the initial selection of patients

to participate in the feasibility study:

1) Five years in conventional methadone maintenance

treatment.

2) Stable employment or other productive use of time

over the past 3 years. (There should be an adequate source of income so that possible diversion

of medication for monetary reasons is unlikely.)

3) No criminal involvement for the previous 3 years.

4) No nonnarcotic drug or alcohol abuse for the

previous 3 years.

5) A record of reliability in the previous clinic

with respect to attendance and not missing

medications.

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6) Indications that further long-term maintenance

will be needed. Such indications might include

previous unsuccessful attempts at detoxification

or a shared belief between the patient and physician that continued maintenance will be

necessary.

7) No need for additional psychotropic medications

or intensive support services.

8) Lack of social ties to illicit narcotic users who

might encourage diversion of medication.

9) Recommendation from a clinician with thorough

knowledge of the patient's treatment history.

10) All patients must be volunteers, and willing to

participate in research evaluations of medical

maintenance.

Intensive intake interviews and supporting documentation from

previous treatment were the primary methods of collecting the

information needed for an admissions decision. Appropriate

specialists or persons having detailed knowledge of the patient,

or both, were consulted to resolve any doubts about whether

patients met specific criteria.

In addition to the formal criteria, admission also required concurrence by the medical maintenance physician that the patient was

appropriate. No formal list of criteria could be expected to

cover all factors that might be important for admission. Expert

clinical judgment is used in the admission decision as in other

medical maintenance treatment decisions.

Under medical maintenance, patients receive treatment in the

office of a hospital-based phvsician. Visits are scheduled

according to need as determined by the physician. Medication

dosage is also determined by the physician, in accordance with

currently accepted good medical practice. The number of days of

medication that are prescribed is also determined by the physician, with an upper limit of a 30-day prescription. Medication is

dispensed from a selected pharmacy, meeting all current requirements for dispensing methadone. Nonmedical supportive services,

e.g., counseling, are provided on an as-needed basis, rather than

by mandated schedule. In order to provide methadone maintenance

within this format, an Investigational New Drug (IND) status for

the project was obtained from the Food and Drug Administration.

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FIRST-YEAR PROGRESS

Admissions

The medical maintenance project began operating in June 1983 at

the Rockefeller University Hospital medical clinic under the

direction of Dr. Vincent P. Dole and Dr. Marie Nyswander. Twentythree ex-street addicts and five "medical-pain" patients were

admitted to the medical maintenance program. The medical-pain

patients were accepted as referrals from pain clinics and physicians, and from inquiries to Dr. Nyswander. These were patients

who required frequent short-acting narcotics for chronic pain

conditions; methadone was a means of managing the iatrogenic

narcotic dependence.

Eleven patients (48 percent) in the ex-street addict group were

admitted from Dr. Nyswander's ongoing caseload at Rockefeller

University Hospital. The remaining 12 (52 percent) were recruited

from other New York City methadone maintenance programs through an

informal network of physicians and program staff members.

Initially, the ex-addict methadone patients were continued for 1

month on their former weekly clinic visit schedules. During this

period, Dr. Nyswander interviewed, evaluated, and observed the new

patients. At the end of the month these patients, with one exception, were placed on a monthly visit schedule. The exception, an

anxious person with impressive achievements in college, professional school, and employment while maintained on methadone,

appeared to need close monitoring. He was placed on a biweekly

reporting schedule. One medical-pain patient, a successful

businessman who travels frequently, was placed on a monthly

schedule. The other medical-pain patients had complicating

problems and were seen much more frequently.

Data Collection

Three forms were created to gather information about the patients.

An intake interview was administered to obtain basic demographics,

and addiction and treatment histories. A physician's log was

created to enter all contacts with the patient; collateral

contacts with other parties; medical, social, and psychiatric

information; methadone dose; drug and alcohol abuse data; and

reasons for possible termination. After 6 months in the project,

the patients completed a questionnaire about their reactions to

medical maintenance.

Patient Characteristics

Table 1 summarizes the ethnicity, sex, marital status, and educational levels of the 22 ex-street addicts and 3 medical patients

who remained in medical maintenance. There is a preponderance of

white males. About 60 percent of the ex-addict group are married

and living with their spouses. The educational level of the

104
ex-addicts is high, 14 percent having finished college and 18

percent having attended graduate or professional schools. Except

in two cases, college education, job skills, and graduate studies

were pursued while patients were in methadone treatment. The mean

age of the ex-addict group in 1983 was 43, which is older than the

mean age of 35 for all New York methadone programs.

TABLE 1. Patient demographic data

Characteristic

Ex-Addicts Medical-Pain

(N=22) (N=3)

Sex

Male

Female

19 2

3 1

Ethnicity

Black

White 1: 3

Hispanic 3

Marital status

Married 14 3

Separated/divorced 3

Widowed 2

Single 3

Education

Less than high school 1

Equivalent to high school 8

Some college 6

College graduate 3

Graduate school 4 3

Table 2 summarizes the ex-addict patients' addiction and criminal

histories. As a group, the patients had an average of 12 years of

addiction and an average of 9 arrests while using opiates.

Sixteen patients spent an average of 2.4 years being incarcerated.

No arrest occurred after entry into methadone treatment.

105
TABLE 2. Addiction, treatment, and arrest histories for 22

es-addict patients

Addiction and treatment histories

Average ages

First used opiates

First entered MMTP

Entered medical maintenance

Average number of years in MMTP

Percentage of cases continuously

in treatment

19

31

43

12

83

Arrest histories prior to methadone treatment

Average ages

First arrested

Last arrested

Number of persons arrested

Average number of arrests

Number of patients incarcerated

Average years in prison for

those incarcerated

19

29

20

9

16

4

Table 3 summarizes the ex-addict patients' income at the time of

intake interviews conducted in the summer and fall of 1983. With

one exception, the patients have not changed jobs and are earning

approximately the same incomes. Because of the increased travel

flexibility within medical maintenance, one patient was able to

substantially increase his income. Thirteen patients (55 percent)

are employed by hospitals that operate methadone programs, They

work as methadone counselors, clinic supervisors, or in an administrative capacity. The remaining 45 percent are employed in

sales, office work, middle management, law, art, and music.

Eighteen percent earn between $30,000 and $40,000 per year, while

59 percent earn between $21,000 and $25,000 per year.

106
TABLE 3. Income of 22 ex-addict patients

Income Level Percent of Patients

$15,000 - $20,000 5

$21,000 - $25,000 59

$26,000 - $30,000 18

$31,000 - $35,000 13

$36,000 - $40,000 5

Medication Levels

The amount of methadone prescribed for the 22 ex-street addict

patients ranges from 20 mg to 80 mg. Table 4 shows the amounts

are equitably distributed into three levels--low (20 mg/day),

medium (30 to 50 mg/day), and high (60 to 80 mg/day).

Irrespective of dosage level, these patients are able to function

without motor or intellectual impairment.

TABLE 4. Stabilization levels of 22 es-addict patients

Stabilization Level Percent of Patients

I 20 mg 32

I I 30 mg - 50 mg 36

III 60 mg - 80 mg 32

During the first 8 months of medical maintenance, the daily

amounts prescribed for three patients were changed. One patient

attempted detoxification, which was not successful because of

increased discomfort, and was then stabilized at 20 mg/day. Two

patients were raised 10 mg/day: one was under emotional stress

because of his wife's serious illness, and the other, who gave

birth, felt more comfortable with the increased dosage.

107
Patient Reactions to Medical Maintenance

Four trends were discerned in the responses of patients to a questionnaire about the medical maintenance pilot project:

1)

2)

Patients now have more mobility and privacy. They

are able to plan extended trips without having to

make arrangements to obtain medication in other

cities or countries. As a consequence of monthly

reporting, one patient relocated to a distant suburban community. As noted above, another reported

a substantial increase in earnings because more

flexible business traveling was permitted by

medical maintenance.

Anxiety about travel to treatment has been reduced.

Given the uncertainties of urban transportation,

some working patients were concerned about being

able to obtain a weekly supply of methadone during

the clinic hours. Anxiety about obtaining medication during storms, periods of illness, or when job

responsibilities prevented them from leaving their

offices has decreased.

3) The patients report their employment situations

have improved. Under weekly reporting schedules

and traditional clinic hours, some patients were

late for work after they had picked up methadone.

Others had to obtain permission to leave work early

to obtain medication. With monthly reporting

schedules, these problems have subsided.

4) The patients also report improved self-esteem and a

perceived reduction of the stigma associated with

methadone maintenance. As one patient succinctly

expressed: "I feel trusted and therefore feel

better about myself." Another summed up her treatment experience as follows: "After 17 years in

treatment with my heroin addiction far behind me,

it is gratifying that I am no longer treated as a

'patient in need of counseling,' being treated the

same as a patient who just began treatment." The

effect of being subjected for years to controlling

regulations and the subsequent loosening of these

regulations elicited the following response from

one patient: "My frame of mind is 100 percent

improved. I feel that I was released from a restrictive and punitive atmosphere. For the first

time in many years, I feel that I'm being treated

as a patient with a medical problem, rather than a

drug addict, who's lucky to be receiving

medication."

108
Discharges

Of the 28 patients officially admitted to the medical maintenance

program, 3 (11 percent) have been terminated. Two were medicalpain patients. One was detoxified and is now seen on a monthly

basis without medication. A second medical-pain patient has an

extensive surgical history and continuous back pain, for which

short-acting narcotics have often been required. Ouring the month

of April this patient did not discuss his medical condition with

Dr. Nyswander, and proper doses of medication could not be prescribed. Subsequently, he was terminated from medical maintenance

and returned to his referring physician for additional treatment.

One patient from the ex-addict group reported no advantages to

medical maintenance and stated that he missed staff members from

his former clinic. After 6 months he requested and received a

transfer back to his previous methadone clinic.

CONCLUSION

In summary, the first year of the medical maintenance study indicates the feasibility of methadone maintenance without mandatory

counseling and with a considerably more flexible medication schedule for a small, highly selected group of patients. Counseling

services were provided on an as-needed basis and appeared sufficient to patients' needs. Noncompliance with the treatment regimen was noted in only one patient (not an ex-addict), which is

quite low compared to noncompliance rates for other chronic

diseases. Patient acceptance of this form of methadone treatment

appears quite high, with patients reporting significant subjective

benefits compared to standard methadone clinic treatment. In the

second year of the feasibility study, medical maintenance will be

expanded to include additional patients and additional physicians.

We expect to add up to 10 additional physicians and up to 120

additional patients.

REFERENCES

Des Jarlais, D.C., and Joseph, H. Methadone patients in

conventional society. Treatment Issue Report 32. New York

City: New York State Division of Substance Abuse Services,

1983.

Des Jarlais, D.C., and Uppal, G.S. Heroin activity in New York

City: 1970-1978.

1980.

Am J Drug Alcohol Abuse 7(3 and 4):335-346,

Dole, V.P., and Nyswander, M.E. Methadone maintenance treatment:

A ten-year perspective. JAMA 235(19):2117-2119, 1976.

Lowinson, J.H. Methadone maintenance in perspective. In:

Lowinson, J.H., and Ruiz, P., eds. Substance Abuse: Clinical

Problems and Perspectives. Baltimore: Williams and Wilkins,

109
AUTHORS

Don C. Des Jarlais, Ph.D.

Herman Joseph, M.A.

New York State Division of Substance

Abuse Services

2 World Trade Center

New York, NY 10047

Vincent P. Dole, M.D.

Marie E. Nyswander, M.D.

Rockefeller University

1230 York Avenue

New York, NY 10021

110
THE ROLE OF EMPLOYMENT

IN THE REHABILITATION OF

HEROIN ADDICTS

Jerome J. Platt, David Metzger

INTRODUCTION

In their 1979 chapter on vocational rehabilitation in the Handbook

on Drug Abuse, Wolkstein and Hastings-Slack noted that few controlled studies existed in the area of vocational rehabilitation

for drug abusers. The few that did exist led them to conclude

that vocational rehabilitation and its goal, employment, seemed to

be related to treatment outcome, but that little was known about

the nature of the relationship. The situation has not changed

significantly since then. In this paper we will examine the role

of work as it relates to the rehabilitation process in heroin

addicts, report on recent findings that help to define and delineate specific elements in the rehabilitation process, and

briefly outline current work in this area.

EMPLOYMENT AND TREATMENT OUTCOME

Employment has been viewed as an essential element in the successful rehabilitation of the heroin addict in methadone treatment.

On this point, Smart, based on a number of investigations he

conducted, stated: "The major factor may be getting a job and not

whether a drug is given or not" (1977, p. 181). Other researchers

agree that for the ex-heroin addict to reach a successful outcome,

employment is crucial in making the expected life adjustments

(Waldorf 1970, Preble and Casey 1976).

Generally, the employed methadone client is more likely to be

successful than the unemployed one, not only in securing employment, but also in meeting other outcome criteria. Vaillant (1966)

and others (Waldorf 1970, Dole and Joseph 1978) have reported that

employment appears to be related to abstinence from opioid and

nonopioid drugs. Other investigators have found a strong association between employment status and criminality among methadone

clients. The employed methadone client is more likely to have

shorter periods of incarceration or fewer instances of it, or both

(Sass and Woodward 1978, Nash 1973). Retention in treatment has

111
also been related to employment. In an effort to stabilize their

lives, clients are maintained on methadone for what are often long

periods of time. Although retention rates in methadone maintenance programs were reported to be around 50 percent overall (NIDA

1976), cumulative evidence consistently indicated that employment

status was directly related to retention in treatment (Babst et

al. 1971, Berle and Lowinson 1970, Chambers et al. 1970, Sells et

al. 1972). Those clients who are employed have a higher retention

rate. The conclusion drawn from these studies is that the

employed client is likely, from all indications, to meet many

criteria used to define a successful treatment experience. The

pattern of these results appears to indicate that to understand

the issues involved in employment, and to understand the factors

involved in overall successful rehabilitation, one must examine

the individual client and his or her personal qualities and

resources.

CHARACTERISTICS OF THE EMPLOYED CLIENT

The abilities and resources of the employed methadone client that

enable him or her to secure and maintain employment are of a

multidimensional nature. A host of internal forces (e.g., values,

confidence, motivation, personal decisions) and external forces

(e.g.) employment opportunities, social matrix) come together to

render the client employable as well as employed. In addressing

these abilities within the context of employment and training of

ex-drug users, Presnall (1975) stated:

One ...can improvise a fairly effective rehabilitation

process, provided an ex-drug user has well developed

survival skills and is not too distant from the

language and cultural value system of the middle class

business world. (p. 1212)

Richman (1966) agreed and further delineated the factors involved

in the success of rehabilitation as the "degree of identification

with and conformity to conventional modes of behavior and the

degree of criminality" (p. 260). There is, in fact, increasing

evidence that it is the "type" of client involved that best

clarifies the relationship found between employment status and

overall success at rehabilitation:

Most of the outcome status variance for which we could

account was related to characteristics of the patients

before they entered the sample treatment program...the

type of patient served may outweigh program impact.

(Mandell et al. 1973, p. 122)

Other researchers have arrived at the same conclusion. Katzker et

al. (1974) and Joe (1973) found that the success experienced on

the various outcome measures they used, such as retention and

employment, appear to depend not on treatment but on the personal

112
qualities and social resources that the individual client has

prior to entering treatment.

The ability to secure employment is, of course, more than simply

going out and getting a job. First, clients who successfully go

out and get jobs placed some value on being employed. Second,

they believed that job opportunities do exist. Third, they had

realistic goals in view of their skills and abilities, and they

had confidence in applying these resources in seeking and securing

employment. Fourth, employed methadone clients were motivated and

made the decision to seek work. Finally, they were successful in

overcoming or dealing with the fears and anxieties associated with

locating, applying for, and being accepted (or rejected) for

employment.

It is also clear that the ability to maintain employment is more

than merely applying the skills required in performing the given

work task. In this regard, Richman (1966) noted:

Work requires at least two attributes, namely the skill

and ability to perform the task required and the social

ability to be part of the social matrix which is the

job environment. (p. 254)

The implication of the above is that the ex-heroin addict, in

becoming "successfully" rehabilitated, must engage in what could

be called a "cultural transition." The extent to which addicts

internalize and identify with the drug subculture, where they feel

accepted, has been explored and documented through the literature

(Chein et al. 1964, Waldorf 1970, Senay 1975, Coombs et al. 1976).

The addict, through involvement in the drug subculture and a drugseeking career, becomes enmeshed in a way of life that is far

removed from that of the dominant culture.

The emoloved methadone client. aiven this success at rehabilitation, appears to have the abilities and resources required to make

this cultural transition. There is. in fact. some evidence that

the employed methadone client is not as far removed from the dominant culture as are addicts in general. Caplovitz (1976), in a

study of working addicts, concluded that the social characteristics of the working addict are more similar to those of the

nonaddict population than to those of addicts in general. This

finding was substantiated by Hughes et al. (1971), who found that

working clients are good prospects for treatment, given their

abilities with respect to psychosocial functioning. Further, the

employed methadone client, according to Dole and Joseph (1978),

has a relatively shorter history of addiction; that is, he has had

less involvement in the drug subculture than the unemployed methadone client has. Finally, there is considerable evidence that a

stable work history prior to admission is indicative of subsequent

113
success at employment (Koenigsburg and Royster 1975, Vaillant

1966); employed methadone clients had experience in applying their

personal and social abilities within a job environment prior to

treatment.

Overall, there appears to be a pattern that emerges from the

literature with respect to employed methadone clients. First,

they are successful not only in securing employment, but also on

other outcome measures; i.e., the employed client is considered

successful in terms of overall rehabilitation. The success

experienced in each of these areas appears, in turn, to be

dependent on personal qualities and resources that typify the

employed methadone client. Finally, employed clients have the

abilities required to seek and gain employment and the social

skills that enable them to interact with the nonaddict population

found in the job environment.

RECENT RESEARCH FINDINGS: A SKILLS APPROACH TO OBTAINING AND

RETAINING EMPLOYMENT

There are very few studies that focus directly upon the issue of

vocational rehabilitation for heroin addicts. In discussing

vocational rehabilitation, however, some redefinition may be

needed. Wolkstein and Hastings-Black (1979) defined it as:

. ..a process in which the client is helped to understand his/her problems and strengths, and is provided

with services which will help him/her become employable

and obtain and hold a job. (p. 159)

Our view, however, is that rather than developing "understanding"

on the part of clients, it would seem as appropriate to provide

them with job-related skills. Such skills are not defined as

relating to the manifest requirements of the job, but to the

interpersonal skills needed in obtaining and retaining employment.

Azrin and his associates (1975) and Hollandsworth et al. (1977)

have demonstrated the value of behaviorally oriented training in

increasing job interview-related skills in unselected unemployed

populations. Azrin and Phillips (1979) later extended their work

to the handicapped, while Kelly et al. (1979) developed a program

for providing job interview-related skills to formerly hospitalized psychiatric patients. These studies clearly suggested the

value of acquiring specific job-seeking behaviors such as asking

relevant questions, responding appropriately to questions about

oneself, and otherwise demonstrating effective interpersonal

behavior. Azrin's program went beyond the interview situation,

employing a job-seeking strategy called the "Job Club," which

focused on obtaining information about job availability, as well

as upon specific interview behaviors. Importantly, participants

in Azrin's Job Club learned to use peers as a source of support

and information during the job-seeking process.

114
With respect to heroin addicts, Hall, Loeb, and their associates

have been most active in developing job-seeking skills. Using a

program they developed with LeVois (Loeb et al. 1982). modeled

after Azrin et al.'s (1975) Job Club, they successfully demonstrated an increase in employment among ex-heroin addicts and

clients in methadone maintenance. In their first study, with exheroin addicts, Hall et al. (1981a) found that their "Job Seeker's

Workshop" significantly increased interview skill and rate of

employment levels. In their second study, with clients in methadone maintenance, Hall et al. (1981b) found similar increases, but

at only marginal levels of significance.

These studies by Hall and her associates are clear examples of

what is needed most with respect to the vocational rehabilitation

of substance abusers--carefully designed, rigorous experimental

evaluations of brief structured interventions that have face

validity for the client. The only notable limitation of the Hall

et al. studies is acknowledged by the authors (1981a) themselves.

They noted that the workshop had a limited objective, increased

employment, and did not address "...the other, very real jobrelated problems which plague ex-drug abusers, including inability

to keep a job..." (p. 451).

Some suggestions regarding the skills (and other variables

involved in obtaining and retaining employment) may be found in

the results of a recent NIDA-sponsored study (Platt et al. 1982)

that evaluated the rehabilitative potential of providing interpersonal cognitive problem-solving training to methadone clients.

One aspect of the research investigated the demographic, psychosocial, treatment involvement, and interpersonal problem-solving

characteristics of clients as these variables related to employment status. Of the 191 methadone clients included in the final

analysis, 25 percent were employed.

Perhaps the most striking finding was that the employed group and

the unemployed group were very similar in demography and what

Platt et al. termed "personal characteristics." While there was

no clear evidence that the employed group was more similar to the

nonaddict population than to the unemployed group, the trends

noted did lend support to past research findings. From the overall study sample, it was noted that white male clients from

nonurban, higher socioeconomic areas were more likely to be

included in the employed group. Also, these clients tended to

have been involved in drug abuse for a shorter time, and thus a

shorter period in which the drug culture, with its attendant

beliefs, attitudes, language, and behavior, could be internalized.

Regardless of the extent to which the values, beliefs, and

attitudes of the drug culture are internalized, it appears that

there remain essential differences in the two cultures that the

methadone client must deal with when involved in a working

environment. As compared to the unemployed clients, employed

methadone clients, interacting within a different social matrix,

115
that of the employed nonaddict population, reported a significantly lower sense of self-confidence in their ability to deal

with social situations. At the same time, the employed client was

more likely than the unemployed client to maintain a relatively

extensive support system. It was also found that employed clients

were not only more likely to be married, but were also more likely

to indicate that, when needed, they had someone to turn to for

help. Most frequently, when faced with a problem, employed

clients--unlike their unemployed counterparts--believed that they

could turn to clinic staff for support.

In addition to having a support system available to them, employed

methadone clients were able to bring to bear problem-solving

skills upon problematic situations. They were able, for instance,

to view problems from various perspectives. They displayed a

stronger ability to make causal connections between actions and

consequences and were also able to cite more solutions to a particular problem. This finding is particularly noteworthy.

Although the two groups were similar in their ability to cite the

various types of problems that people routinely encounter, the

employed methadone client was able to conceive of significantly

more alternative solutions. Although cognitive abilities are usually viewed as stable constructs, there is ample evidence that

these abilities can change with time, training, or experience, or

all of these. Although demographically very similar to the

unemployed clients and essentially equivalent in terms of past and

current treatment involvements, employed clients were receiving

significantly higher doses of methadone ( = 50 mg versus =

38 mg). Our data cannot define a cause-and-effect relationship

between methadone dose and employment. However, it is our belief

that clinics may be more willing to maintain clients at higher

dose levels when they are engaged in activities generally regarded

as productive and successful.

Together, the above similarities and differences suggest that

employment is related to interpersonal cognitive skills (and, of

course, job availability). There were few demographic and

treatment-related differences other than clinic location and dose

between those who had jobs and those who did not. While employment may he an almost universal goal of treatment programs and

clients alike, the data also suggest that gaining employment

brings with it an increased need for supportive counseling

services.

VOCATIONAL PROBLEM-SOLVING SKILLS TRAINING: THE HAHNEMANN PROJECT

Based upon the above findings, which we believe highlight the

essential role of interpersonal skills in seeking and maintaining

work, we have developed a pilot intervention program that will be

empirically evaluated over the next 3 years.

One focus of this project will be to examine different classes of

variables in explaining employment. A second focus will be on

116
teaching and directing participants to clarify and act upon their

own work-related problems. Some programs, either directly or by

implication, make promises that cannot be kept with certainty:

that is, they set overly optimistic expectations, such as job

placement, vocational expertise, and so on. It is crucial that

realistic expectations be established at the start. This program

is not a job-placement program, nor is it a vocational training

program. The group series is a program designed to lead participants through a process of self-examination regarding their

feelings, attitudes, and motivations toward work, and to teach a

process for overcoming vocational problems.

It is our belief that getting a job or keeping a job is a job in

itself. These groups will provide an approach to looking at oneself in relation to finding work and keeping it.

The underlying construct of these sessions is the Training in

Interpersonal Problem-Solving model (TIPS), as developed by Platt

et al. (1979). This problem-solving, cognitive training model may

be briefly summarized as consisting of three phases: 1) problem

clarification, 2) resource awareness, and 3) action and readiness.

Ten one-and-a-half-hour group sessions focus upon teaching this

process to drug treatment clients. The program is intended to aid

in a current assessment of an individual's status regarding work.

We will not attempt to deal with historical factors in an individual's life that have evolved to produce their current situation.

While this is obviously an important issue, the program begins

with the existence of the problem and attemots to Drovide strategies for addressing the problem. We want clients to move away

from thinking about "What could have been?" or "What should I have

done?" to "What am I going to do now?"

The employment problems will be different for each participant;

consequently, solutions will also be different for each

individual. However, the process of moving from the problem to

the solution can be the same for all. It is this process upon

which this group sequence is based and designed to teach. Success

of the group will be assessed on the basis of how well the participants have learned the process and incorporated it into the

achievement of their own vocational goals through action.

Past demonstrations of the efficacy of the problem-solving therapy

approach have been focused upon teaching a set of interpersonal

skills, which have been empirically tested and related to

adjustment. This project represents an attempt to sharply focus

that process upon vocational issues. Our success with past

training programs in problem-solving encourages us to believe

that, with this more highly focused approach, application of the

acquired skills will be more directly facilitated. In fact, with

this focus, individuals within the group will be required to apply

the process as it is being taught and to assist each other in the

process of vocational problem-solving.

117
One additional point must be stressed: the group program is

designed to place the responsibility for action upon the

individual. We will train the clients to become, in essence, the

procurers of services they define as necessary to overcome their

own barriers to employment. An important focus of the intervention is thus upon motivating clients to act upon their own employment problems, to use the resources available to them. As stated

previously, each client has a unique set of historical and current

issues that may impede goal-directed behavior. The fact that

employment problems are individualized in nature means that the

specific solution to these problems must also be individualized.

While one client may face an educational barrier, others may be

stalled in their search for employment because of a recent work

failure or poor work history. The common factor among these

clients is that they are unemployed and must act to overcome their

own barriers to employment. The focus of the intervention is upon

involving clients in a process of self-examination and training in

solving employment-related problems.

CONCLUSIONS

At this point, the relative lack of empirical data on the efficacy

of vocational rehabilitation programs for heroin addicts is painfully obvious. At the same time, research appears to be beginning

on what works in increasing both job-acquisition and job-retention

skills. It is hoped that current research on the role of work in

rehabilitation will yield an increased understanding of the

contribution of different classes of variables (personal and

demographic characteristics, treatment involvement, psychosocial,

and interpersonal cognitive problem-solving skills).

Based on our experience to date, however, we can summarize our

ideas concerning the "ideal" intervention program. First, it

should meet an important need of a large proportion of the heroin

addict population. Since our own data as well as those provided

bv others (Wolkstein and Hastinas-Black 1979) indicate approximately a 75 percent unemployment rate, the need is obvious if what

we believe about the value of employment is substantiated.

Secondly, the ideal treatment program, in our opinion, is one of

brief duration--eight to ten sessions because of the difficulties

in holding addict populations in treatment, Third, the ideal

location for placement of a vocational rehabilitation program

should be the clinic itself since this placement maximizes

attendance. Fourth, there is no reason for vocational rehabilitation to be isolated from other treatment elements. If anything,

its importance should be stressed as part of an integrated treatment program. Fifth, the staff members who implement the program

need not be at the doctoral, or even master's, level. In fact,

our experience suggests that such leaders may be too closely

allied with a clinical philosophy and therapeutic style inconsistent with the problem-solving training approach used here and thus

have a tendency to "stray" from the programmed content of the

118
intervention. Also, individuals highly familiar with the practical aspects of employment difficulties for addicts should be used.

The program we are currently studying brings with it many

questions. These include 1) the form of the most efficacious

vocational skill acquisition program, 2) the nature of the client

characteristics that facilitate skill acquisition and their use,

3) the possible negative consequences, if any, of providing

skills, and 4) the long-term psychosocial impact of seeking and

gaining employment.

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Azrin, N.H., and Phillips, R.A. The job club method for the

handicapped: A comparative outcome study. Behav Ther 23:144-

155, 1979.

Azrin, N.H.; Flores, T.; and Kaplan, S.J. Job finding club: A

group assisted program for obtaining employment. Behav

Ther 13:17-28, 1975.

Babst, D.V.; Chambers, C.D.; and Warner, A. Patient characteristics associated with retention in a methadone maintenance

program. Br J Addict 66:195-204, 1971.

Bass, U.F., and Woodward, J.A. Skills Training and Employment for

Ex-Addicts in Washington, D.C. National Institute on Drug Abuse

Treatment Services Research Report. Washington, D.C.: Supt. of

Docs., U.S. Govt. Print. Off., 1978.

Berle, B., and Lowinson, J. Comparative study of three groups of

patients at the Brown State Hospital Methadone Maintenance

Program. In: Proceedings of the Third National Conference on

Methadone Treatment. Washington, D.C.: Supt. of Docs., U.S.

Govt. Print. Off. , 1970

Caplowitz, D. The Working Addict. New York: City University of

New York. 1976

Coombs

Drug

Dole.

R.H.; Fry, L.J.; and Lewis, P.T., eds. Socialization in

Cambridge, Mass.: Shenkman Publishing Co., 1976.

V.P., and Joseph, H. "The Long-term Outcome of Patients

Treated with Methadone Maintenance." Paper presented at the New

York Academy of Sciences Conference on Recent Developments in

Chemotherapy of Narcotic Addiction, Washington, D.C., November

3-4, 1978.

Chambers, C.D.; Babst, D.V.; and Warner, A. Characteristics

predicting long-term retention in methadone maintenance

treatment. In: Proceedings of the Third National Conference on

Methadone Treatment USPHS Pub. No. 2172. Washington, D.C.:

Supt. of Docs., U.S. Govt. Print. Off., 1970.

Chein, I.; Gerard, D.L.; Lee, R.S.; and Rosenfield, E. The Road

to H.: Narcotics, Delinquency, and Social Policy. New York;

Basic Books. 1964.

Abuse.

Hall, S.M.; Loeb, P.; Coyne, K.; and Cooper, J. Increasing

employment in ex-heroin addicts. I: Criminal justice sample.

Behav Ther 12:443-452, 1981a.

119
Hall, S.M.; Loeb, P.; LeVois, P.; and Cooper, J. Increasing

employment in ex-heroin addicts. II. Methadone maintenance

sample. Behav Ther 12:453-460, 1981b.

Hollandsworth, J.G.; Dressel, M.E.; and Stevens, J. Use of behavioral versus traditional procedures for increasing job interviewing skills. J Counsel Psychol 24:505-510, 1977.

Hughes, P.H.; Crawford, G.A.; Barker, N.W.; Schumann, S.; and

Jaffe, J.H. The social structure of a heroin coping community.

Am J Psychiat 128:551-558, 1971.

Joe, G.W. Retention in Treatment for Drug Users in the DARP:

1969-1971 Admissions, IBR Report No. 73. Fort Worth, Texas:

Texas Christian University, Institute of Behavioral Research,

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Katzker, E.; Steer, R.A.; and Schut, J. Differentiation of longterm methadone patients from their admission cohorts. Int J

Addict 14:281-287. 1974.

Kelly, J.A.; Laughlin, C.; Clairborne, M.; and Patterson, J. A

group procedure for teaching job interviewing skills to formerly

hospitalized psychiatric patients. Behav Ther 10:299-310, 1979.

Koenigsberg, L., and Royster, E. Jobs for Drug Abuse Treatment

Program Clients. Rockville, Md.: National Institute on Drug

Abuse, 1975.

Loeb, P.; LeVois, M.; and Hall, S.M. Leader's Manual: The Job

Seekers' Workshop. National Institute on Drug Abuse, Services

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Mandell. W.; Goldschmidt. P.G.; and Grover. P. Interdrug--An

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(TIPS):

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Preble, E., and Casey, J. Taking care of business - the heroin

user's life on the street. Int J Addict 4:1-24, 1969.

Presnall, L.F. The employment and training of ex-druq users: A

three-way interaction. In: Senay. E., et al.. eds.

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Richman, S. Return to productive community living: Reflections

on the twenty-year program experience of the New York State

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1977.

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pp. 159-164.

AUTHORS

Jerome J. Platt, Ph.D.

David Metzger, M.S.

Hahnemann University

School of Medicine

Broad & Vine

Philadelphia, PA 19102-1192

121

WHO IS SERVING DRUG ABUSE

CLIENTS: TREATMENT DELIVERY

BY PROFESSIONALS VERSUS

PARAPROFESSIONALS, BY PAID

STAFF VERSUS VOLUNTEERS

Leona S. Aiken,

Leonard LoSciuto, Mary Ausetts

INTROOUCTION

In two national studies we have detailed who is treating drug

addicts. and, from staff evaluation and client progress, how well

they are providing these services. In our first study, we contrasted three groups of paid counselors in drug-free outpatient

(DF) and methadone maintenance (MM) modalities: 1) professional

counselors with no addiction background who held at least a bachelor of arts degree (PROS); 2) ex-addict paraprofessional counselors who did not hold a bachelor's degree (EXAs); and 3) non-exaddict paraprofessional counselors who had neither a bachelor's

degree nor a history of drug addiction (NEAs). These counselor

groups were contrasted in terms of their functions and activities

in the program, their attitudes to clients, the attitudes of

clients to them, and the progress of their clients in treatment

(Aiken et al. 1984a,b; LoSciuto et al. 1984; Aiken and LoSciuto

1984). In the second study we examined the services provided by

volunteers in more than 100 drug-free outpatient and therapeutic

community (TC) programs nationwide. Here we detailed the services

provided by both specialized volunteers such as physicians,

lawyers, and psychologists, and, more importantly for our purposes

here, by volunteer counselors. We explored the views of program

administrators and paid counselors on the worth of program volunteers, and on the staff support, training, and supervision

required to use volunteers. We examined in some detail sources of

volunteers and their motivations for and satisfactions with volunteering (Aiken et al. 1981).

Background of the Paraprofessional Study

The comprehensive nature of our study of counselor groups contrasts with the literature on paraprofessional versus professional

program staff. There has been some consensus concerning the advantage of counseling by indigenous paraprofessionals such as the

ex-addicts of our first study. However, few studies of the effectiveness of these counselors versus more traditional professionals

123
exist (Ottomanelli 1978). In the methadone maintenance modality,

Brown and Thompson (1976) provided l-year evaluations of clients

assigned to ex-addict and nonaddict counselors; they reported no

differences in client retention in treatment, arrest rate, and

employment. More recently, Longwell et al. (1978) and Connett

(1980) compared the drug use of clients of professional and para-

(professional counselors, again reporting no differences in the

percentage of clean urines of the two client groups. Finally,

Ottomanelli (1973) found no differential personality changes in

clients assigned to professional counselors (with master's degrees) versus methadone-maintained ex-heroin addicts. While these

studies apparently support a lack of difference between paraprofessionals and professionals in counseling quality, only the

study by Brown and Thompson had samples of sufficient size and

therefore statistical power to warrant such a conclusion. This

literature suffers from the same limitations on validity of

statistical conclusions as the more extensive literature on paraprofessional effectiveness within the mental health field (Durlak

1979, Hattie et al. 1984, Nietzel and Fisher 1981). The present

study was designed to overcome problems of statistical power, so

that whatever differences might exist among the counselor groups

could emerge.

Background of the Volunteer Study

According to the 1980 National Drug Abuse Treatment Utilization

Survey (NDATUS) (National Institute on Drug Abuse 1980), only 4

percent of the fulltime equivalent counselors in all drug treatment programs in this country were volunteers. For prior years,

headcounts, not fulltime equivalents, were reported by NDATUS.

These counts give a different picture of volunteer use. The

percent of all counselors who were volunteers was 30 percent in

1976, 24 percent in 1977, and 23 percent in 1978. (The most

recent NDATUS report of 1982 did not gather data comparable to

these earlier reports.) In 1978, the percentage of volunteer

counselors who were paraprofessionals without degrees was 76

percent versus 46 percent for paid counselors. Examined from the

perspective of volunteers, more than half the volunteers in drug

treatment programs serve as counselors. Overall, a sizable part

of our drug treatment nationally is being provided by volunteers

who do not hold a bachelor's degree.

Ausetts et al. (1980) provided further analysis of volunteerism in

drug treatment based on a program-by-program analysis of the

federally funded programs listed in the 1976 NDATUS survey.

Volunteers were not uniformly distributed across the country. In

large East Coast Standard Metropolitan Statistical Areas (SMSAs)

with substantial federally funded treatment programming, volunteering was surprisingly low: fewer than 1 percent of treatment

staff in the New York City SMSA were volunteers; for Washington,

D.C., 9 percent were volunteers. In contrast, volunteers

constituted 20 percent of staff in San Francisco and 25 percent in

Los Angeles. Volunteers were not uniformly distributed across

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modalities--almost no methadone maintenance programs had

volunteers, but close to half of therapeutic community and drugfree outpatient programs did.

Ausetts et al. (1980) also provided an extensive literature review

on the volunteer movement in drug abuse, alcoholism, mental

health, and corrections. They analyzed the functions and specific

activities of volunteers in these service delivery areas. Volunteers have been reported to participate in a full range of program

activities: community education, interagency relationships,

program administration, counseling in the community, client administration, personal aid to clients, psychological and psychiatric

services, medical and dental services, legal services, and

research. The shift in motivations for volunteering that occurred

in the 19705, i.e., from response to broad social goals and societal needs to more personal self-awareness and self-actualization

is described (see also Smith 1974, Suarez and Ricketson 1974).

Evaluations of volunteer effectiveness are reviewed; these mainly

are confined to the criminal justice field, where volunteer programs have met with mixed success (see also Cook and Scioli 1975),

and to the mental health area, where reports have been more

positive.

Finally, of particular importance are issues of volunteer recruitment, selection, and training, and the implementation of volunteer

programs, also addressed by Ausetts et al. (1980). Volunteer

pools have included university students, professionals, retired

persons, and clients and ex-clients. Recruitment has been accomplished through appearances by program staff, advertisements, and

distribution of literature. Not unexpectedly, selection and

training have varied widely in intensity and care.

In all, the extensive literature on volunteerism addresses the

many issues confronting program planners who wish to use

volunteers. However, the major sources of information on volunteers have been the mental health and criminal justice fields, not

that of substance abuse. Our investigation complements this

literature by addressing volunteer use in drug treatment.

THE PARAPROFESSIONAL STUDY

In the paraprofessional study we aimed to examine differences

among three distinct groups of counselors in the drug treatment

field: 1) professionals with degrees (PROS); 2) ex-addict

paraprofessionals without degrees (EXAs); and 3) paraprofessionals

without degrees with no addiction background (NEAs). Across 16

programs in 5 major cities we surveyed 82 counselors and 302 of

their clients. The programs chosen were primarily ones in which

the three groups of counselors were simultaneously employed,

permitting maximum divergence of roles to occur.

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The study is divided into three components. The first is a consideration of counselors' backgrounds and roles (Aiken et al.

1984a). The second is an attitudinal study (LoSciuto et al.

1984). The third is a consideration of clients' progress in

treatment (Aiken et al. 1984b). The thrust of all aspects of the

study was to identify differences among the counselor groups.

The study began with an in-depth documentation of the three

groups' drug use and academic and experiential backgrounds. An

analysis was also done of the drug use, drug treatment, and criminal, educational, and employment histories of their clients, to

determine whether clients were differentially assigned to the

counselor groups. A job analysis of the counselor's role was

done, covering 41 activities in 11 areas ranging from community

education to staff administration.

In the attitudinal component of the study, counselors reported on

the major causes of drug use, the critical factors of treatment

success, their definition of treatment success, their expectations

for clients, and their perceptions of drug abuse clients.

Clients, in turn, reported on their counselors' knowledge of drugs

and the streets, their competence, and the quality of their

relationships with clients. Clients described problems they would

bring to their counselors, their perceptions of counselors'

willingness to help, and their expectations for themselves.

In the client progress component of the study, clients reported

about two points in time--the point of entry into treatment and

the time of the interview. Counselors reported about client

status at the time of the interview to corroborate client

accounts. The counselors then provided followup data on the

clients 4 months later. At all points, clients' drug use,

schooling, employment, and criminal involvement were considered.

Method

Programs. Nine methadone-maintenance (MM) and six drug-free (DF)

programs plus a sixteenth program with separate MM and DF units

were visited. These programs were in New York, Washington, D.C.,

Los Angeles, San Francisco, and Chicago.

Across programs, 31 PRO, 20 NEA, and 31 EXA counselors were interviewed. Then clients of 116 PRO, 71 NEA, and 115 EXA counselors

were randomly chosen by the study staff for interviews. We fell 8

percent short of our goal of four clients interviewed per

counselor. Finally, we interviewed 29 program administrators.

Four months after the site interviews we performed a mail followup

study of the progress of the clients we had interviewed. Counselors described individual clients' status, whether or not the

clients had remained in treatment. Followup data were collected

on 257 of the original 302 clients (86 percent).

126
Findings: Counselor and Client Background and Counselor Role

Counselor background. The demographics of the three counselor

groups varied considerably. They differed in ethnic composition:

PROS were 67 percent white/Anglo, while NEAs and EXAs were 70

Percent black. Mean ages were 30 years, PROS; 36, NEAs; and 39,

EXAs. The percentage of males was 48 percent, PROS; 60 percent,

NEAs; and 81 percent, EXAs.

PROS had worked in their programs about 1.5 years; NEAs, 3 years;

and EXAs, 2 years. Prior to their current position, PROS had had

an average of only 7 months' drug counseling experience, as

opposed to 13 months for NEAs and 16 for EXAs.

In addition to bachelor's degrees, 42 percent of PROS held

master's degrees, and another 29 percent had taken some graduate

courses. The rates of in-service training differed across groups:

80 percent of NEAs had received such training, but only 58 percent

of PROS and 42 percent of EXAs had. Counselors were asked

whether, over all sources of training, they had studied nine areas

relevant to the counselor role, including counseling techniques,

drug effects, and drug laws. Though they had had quite different

sources of training, the three groups did not differ in incidence

of having received training on any topic.

Almost half the PROS, only 15 percent of NEAs, and, of course, all

EXAs reported having used various drugs. All EXAs had been

frequent heroin users; all but two had been in drug treatment.

Client background. Client backgrounds were examined to uncover

any evidence for differential assignment of clients to counselors

of the three groups.

Clients of the three groups were very similar demographically.

Two-thirds of the clients in each group were male; half in each

group were black; another third in each were white; the remainder,

Spanish-American. The three groups differed slightly, but

significantly, in age, with client ages averaging 29 years old for

PROS, 32 for NEAs, and 30 for EXAs.

Clients reported their years of any drug use, years of continuing

use, frequency of use in the year prior to entry, and frequency of

use in the 30 days prior to entry for 12 drug categories. There

were no differences in the MM modality; in the DF modality clients

of PROS had used alcohol more often than other clients in the 30

days prior to treatment. Again in the DF modality, clients of

PROS had on average one more treatment episode than those of NEAs.

More clients of EXAs had been in jail in the year but not the 30

days prior to treatment. Equal rates of clients in all groups

were in treatment as a result of an arrest.

Groups did not differ in educational and employment history.

127
In summary, four differences among groups were detected over 97

measures of difference among groups. There was no cohesive

picture of differential assignment of clients to counselor groups.

Counselor roles. EXAs worked longer hours than PROS did but

earned an average of $900 a year less than PROS. Caseloads were

equal in size across groups. PROS spent slightly more time per

week than EXAs in individual counseling; the reverse was true for

group counseling. Across these measures, NEAs fell between PROS

and EXAs.

Counselors reported their frequency of involvement in 41 activities covering 11 areas: community education, clerical and service

duties, control and enforcement, socializing with clients,

counseling in the community, personal aid to clients, administration of clients, administration of the program, counseling in the

treatment center, psychological assessment, and staff training.

With separate Multivariate Analyses of Variance applied to the

activities in each of the 11 areas, differences emerged in three

areas: community education (p<.lO), socializing with clients

(p<.10), and counseling in the community (p=.O5). All three areas

involved work with clients outside the program. In these three

areas, EXAs were consistently more involved.

These overall results suggested that EXAs as a group might be

characterized as being more active outside the program. Actually,

this was not so, as indicated by discriminant analyses performed

to determine the extent to which individual counselors would be

classified as similar to their own versus other counselor groups.

In separate discriminant analyses applied to the community education and to the socializing with clients activity clusters, 36

percent and 48 percent, respectively, of EXAs were classified as

being statistically more similar to PROS than they were to other

EXAs. In sum, then, it was a subset of EXAs who differed from the

other counselors at all, and then only on those activities that

took them outside the program.

Administrators apparently supported the idea of equivalent counselor roles across almost all of the 41 activities. Administrators thought that PROS more than the other groups should be

involved in psychological testing, and they supported the extensive participation of EXAs in community education. Other than

these, few differences emerged in administrators' views of the

appropriateness of counselors' involvement by group.

Summary. The demographics and the educational and experiential

backgrounds of the three counselor groups were markedly different.

Of course, PROS had the most extensive academic backgrounds. In

contrast, NEAs had received substantially more in-service training

than had the other groups. Despite the differences in hackground,

the groups reported equal prevalence of having received training

in a variety of drug-treatment-related areas.

128
One might have expected selective assignment of clients to counselors, based on the perceived strengths of each counselor group.

Little evidence of selective assignment was noted, based on 97

measures of drug use, treatment, and educational, employment, and

criminal history.

Counselor roles in the program were also quite similar, with

counselors of the three groups having equal involvement in most

dimensions of counseling-related activities. The one exception

was that for several activities that took counselors into the

community, a subset of the EXAs were more active than all other

counselors.

Considered across client characteristics and job-related activities, there was almost no evidence of differences among counselor

groups. The programs chosen for analysis were ones that provided

the greatest opportunity for role differentiation, since all

counselor groups existed in all but one program surveyed.

Findings: Counselor and Client Attitudes and Expectations

While counselors' roles were notably consistent across groups, it

was possible that their backgrounds had conditioned differences in

their views of drug addiction, drug addicts, and drug treatment.

Clients also might respond differently to counselors of the three

types.

Counselor attitudes and expectations. Counselors, asked to rank

six potential reasons for drug abuse, agreed across groups that

peer pressure was the most important, and poverty and discrimination the least important factor (intergroup reliability coefficient = .97). The groups also agreed that among four factors,

the client was the most important factor in treatment (intergroup

reliability coefficient = .99). The groups, in giving open-ended

definitions of treatment success, most commonly included becoming

and remaining drug-free (29 percent of PROS' comments, 31 percent

of NEAs', and 23 percent of EXAs') and leading a "normal, mainstream" existence (25 percent of PROS, 26 percent of NEAs, 20

percent of EXAs). The only group difference of note was that EXAs

mentioned such psychological adjustment factors as coping, sense

of self-sufficiency, and self-awareness more frequently than the

other groups did; 32 percent of EXAs, 16 percent of PROS, and 15

percent of NEAs mentioned these factors.

Ratings by counselors of the likelihood of clients' sustaining 10

treatment outcomes again yielded substantial convergence among the

groups. NEAs were less optimistic that clients would have good

mental health; EXAs, more optimistic that clients would remain

drug free. All groups agreed in their ratings of the likelihood

that clients would get and hold legal jobs, be crime free, enjoy

physical health, and have good productive lives and family

relationships. They all agreed that it was unlikely that clients

129
would have no further need for treatment a year after leaving the

program.

Counselors characterized drug abuse clients on 19 statements concerning "the average drug abuse client in their program," e.g.,

mentally ill, victims of society, morally weak, reachable, likely

to steal. The counselor groups converged on all items (intergroup

reliability coefficient = .93). Most notably they all agreed that

clients were not criminal by nature, that they were reachable, and

that they were capable of real and permanent change.

Perhaps surprisingly, all three counselor groups disayreed to the

same extent with two items concerning the background required to

handle clients--"There is no substitute for coursework in counseling or social work for learning how to deal with clients," and

"Unless you have a lot of education, most clients think you cannot

help them." Though all three groups disagreed with a third item,

"You cannot really understand a client's problems unless you have

had the same problems yourself," EXAs disagreed less strongly than

did the other groups. The groups agreed on items concerning the

control of clients in the therapeutic relationship, and more

broadly, on items concerning how clients and their counselors

should interact.

Clients' attitudes and expectations. Clients first rated their

counselors along 30 items subsumed under three dimensions:

1) counselor knowledge of drugs and the street (5 items), 2) counselor competence to understand and help the client (12 items}, and

3) quality of counselor-client relationship (13 items). Clients

of EXAs viewed their counselors as more knowledgeable than other

clients viewed their counselors on all items pertaining to drugs

and the street. In addition, clients of EXAs endorsed more

strongly the notion that they got something from counseling

sessions. Clients of EXAs agreed with clients of the other

counselors on all other items.

Clients characterized what they believed to be their counselors'

views on the 19 statements concerning the "average drug abuse

client in their program"; their counselors had also rated these

same items. Correlations between mean responses of clients and

counselors in a group across the 19 items were strony:

r(17) = .81 for PROS' clients, .66 for NEAs', and .78 for EXAs'.

The only variation among the client groups was that clients of

EXAs believed their counselors would see drug abuse clients in a

more negative light compared to clients of the other counselor

groups, i.e., as more likely to steal, more antisocial, and more

likely to be dangerous.

Clients described their expectations for the future. Clients of

the three groups agreed highly over 10 items (interyroup reliability coefficient = .99). They had much higher expectations than

their counselors, however.

130
Asked what problems they were willing to bring to their counselors, clients all were more willing to bring drug-related

problems than other, more personal, problems. When aggregated

over a list of 10 problems, the average percentage of clients who

said it was likely that they would bring a problem to the counselor was slightly higher for clients of EXAs (65 percent) than

for clients of PROS (61 percent) or NEAs (60 percent).

Clients of EXAs also were more likely than clients of the other

two counselor groups to believe that their counselors would participate with them in six counseling-related activities, e.g.,

visiting the client at work or in the hospital, going to court to

testify (on average 86 percent of PROS' clients, 88 percent of

NEAs', and 92 percent of EXAs' across six activities). For participation in more personal activities, e.g., socializing with

clients, differences were more dramatic in favor of EXAs (on

average 59 percent of PROS' clients, 70 percent of NEAs', and 76

percent of EXAs'). The pattern was similar in response to the

question of whether clients would want their counselors to participate in the counseling-related activities (71 percent of PROS',

79 percent NEAs', and 78 percent of EXAs'), and the more personal

activities (40 percent of PROS', 48 percent of NEAs', and 53

percent of EXAs'), though NEAs as well as EXAs were favored here.

Summary. Counselors showed remarkable agreement over many areas:

reasons for the onset of drug abuse, factors important for treatment success, the definition of treatment success, the likelihood

of sustained treatment outcomes, counselor background required to

treat clients, the nature of client-counselor relationships, and

the characteristics of drug abuse clients. It was clients, in

contrast, who exhibited differential beliefs about their

counselors. Clients of EXAs believed their counselors to be more

knowledgable about drugs and the street, and to offer more in

counseling sessions. Clients of EXAs were slightly more willing

than clients of the other counselors to bring problems to their

counselors; they believed more strongly that the counselors would

be willing to help them, and actually wanted their counselors to

participate in solving both counseling-related and personal

problems.

Findings: Progress of Clients in Treatment

Counselors in the three groups held notably similar views, and

their roles in the program were markedly alike. However, the

quality of their participation in the counseling function may have

occasioned differences in client progress in treatment.

Initial differences among client groups. The extensive assessment

of client status in the year, and more specifically the month,

prior to treatment entry had yielded essentially no evidence of

differences in assignment of clients to counselors. Moreover,

clients of the three groups did not differ in the length of time

they had been in treatment prior to the first interview.

131
Methadone clients averaged 21 months in treatment before the

interview; drug-free outpatient clients averaged 7 months.

Lastly, clients in the three groups did not differ in the amount

of treatment time with their current counselors (80 percent and 86

percent of all time with current counselors for the MM and DF

modalities, respectively). In all, there were no systematic differences among clients of the three counselor groups that would

distort the assessment of client progress as a function of

counselor group.

Drug use. Clients and their counselors estimated client use frequency of 12 categories of drugs in the 30 days prior to the first

interview: marijuana/hashish, drugstore items containing drugs,

inhalants, hallucinogens, amphetamines, barbiturates, sedatives

and tranquilizers, cocaine, heroin, illegal methadone, other

opiates, and alcohol to excess. (See Aiken and LoSciuto 1984 for

an extended treatment of counselor-client agreement in estimation

of client drug use.) Use in all but three categories--

marijuana/hashish, sedatives and tranquilizers, and heroin--was

low; rates of any use did not differ across groups. In the MM

modality, the frequency of use of marijuana, sedatives, and heroin

did not differ across counselor groups, with pretreatment use

level controlled. One difference was noted in the DF modality:

decline in use of marijuana from the 30 days prior to treatment

entry to the 30 days prior to the interview. Clients of EXAs

showed the greatest decline.

Counselors at the 4-month followup again reported the frequency of

use of each of the 12 categories of drugs. For clients who

remained in treatment, the report covered the 30 days prior to the

followup. For those who had left the program, the report covered

the 30 days prior to leaving. In the DF modality there were no

differences in rates of use. In the MM modality differences were

found in three nonopiate categories. Clients of EXAs had the

highest use of barbiturates; clients of NEAs, amphetamines;

clients of PROS, drugstore items.

Finally, asked what their counselors had done to help them become

and remain drug-free, 20 percent of PROS' clients, 13 percent of

NEAs', and 9 percent of EXAs' said their counselors had done

nothing.

Education and employment. PROS' clients, more often than those of

the other two groups, received any schooling in the 30 days prior

to the interview (22 percent for PROS', 18 percent for NEAs', and

11 percent for EXAs'). There had been no differences among the

groups in the 30 days prior to treatment entry (10 percent PROS',

11 percent NEAs', and 9 percent EXAs'). At followup, approximately equal percentages of each client group were in vocational

school; however, clients of PROS again had the educational advantage for academic programs (26 percent PROs' clients enrolled, 11

percent NEAs', and 9 percent EXAs'). Part, hut not all, of the

differences among groups could be accounted for, by a small

132
interaction between client age and education level. In all, 18

percent of PROS' clients, 6 percent of NEAs', and 12 percent of

EXAs' held high school diplomas or GEDs and were also between the

ages of 16 and 25, an age range in which clients might consider

pursuing a college education.

No differences existed at any point in the rates of employment of

clients across groups, or, for female clients, in their rates of

being housewives.

Criminality. Clients did not differ in arrest rates or rates of

being jailed in the 30 days prior to treatment entry, 30 days

prior to first interview, or 30 days prior to followup.

Quality of life. During the initial interview only, clients were

interviewed about the quality of their lives. Topics included:

1) participation in routine chores and activities (22 items),

2) participation in antisocial activities (11 items), 3) physical

health (3 items), 4) social isolation versus nonisolation (6

items), and 5) physical environment (3 items). No differences

emerged on any items.

Summary. Evaluation of client progress was based on client status

at three points in time: the 30 days prior to treatment entry,

cross-sectionally the 30 days prior to the first interview, and 30

days prior to a 4-month followup (or leaving the program). In

only one area, education, did any difference emerge among the

clients of the three groups, with the advantage accruing to PROS'

clients. Some part of this advantage may have been attributable

to a demographic interaction--a somewhat higher proportion of

college-age clients who held high school diplomas or GED degrees

in the PRO group.

Discussion

We have amassed evidence on the following four points:

1) PRO, NEA, and EXA counselor groups have highly

similar roles in their programs.

2) Despite their vastly different experiential backgrounds, these groups have highly convergent views

of drug abuse, drug addicts, and drug treatment.

3) Clients are not assigned selectively to one or

another counselor group based on the clients'

histories.

4) With the exception of educational pursuits, the

clients of the three groups make equivalent

progress in treatment.

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In sum, we are making an argument for a "no difference" conclusion, a conclusion that can be supported only in the context of

adequate statistical power to detect any differences that might

exist in the data (Cohen 1977). Statistical power analyses were

performed on the two data segments within which counselor groups

comparisons were made: comparisons among the 82 counselors, and

comparisons among their 302 clients. For comparisons among counselors at a conventional level of significance (.05), the power

for detecting effects of moderate size was 80 percent, a level of

power now conventionally acceptable in psychological research

(Cohen 1977). For comparisons among clients on continuous measures, power approached 100 percent; for comparisons on discrete

measures, almost 80 percent. The one exception to this high level

of power was that for comparisons of drug-use levels among clients

in the DF modality at followup; here power was 72 percent for a

Type I error probability of .05, but it rose to 82 percent if the

probability of Type I error rose to .1O. Examined across the many

comparisons made in the study, the power was adequate for our "no

difference" conclusion.

With this broad conclusion of no difference among counselor

groups, are there further questions we need to ask? Two suggest

themselves: 1) Do the counselor groups differ in their ability to

handle "special needs" clients, e.g., the severely disturbed? and

2) Would a finer stratification of the "professional" category

into those who hold only a bachelor's degree versus those with

advanced clinical training reveal undetected differences in

effectiveness?

Our selection of clients was random--we chose a random sample of

clients of each counselor's caseload. We did not systematically

sample classes of clients of interest, e.g., those who were emotionally disturbed, or those with extensive criminal histories.

Perhaps in such cases unique counselor backgrounds would lead to

differences in effectiveness. We might find interactions between

client outcomes by subgroup and counselor group in these more

extreme cases.

In this publication a number of treatment strategies are being

discussed--group therapy, behavioral therapy, family therapy. We

did not examine in our study how the various counselor groups

fared in providing these various treatment strategies. Rather, we

aggregated across treatment strategies. A more careful study of

the interaction of counselor background with treatment strategy

would be useful.

In considering what counselors are suited to delivering what sorts

of therapy to what type of clients, a precise definition of "professional counselors" is needed. In our study all counselors with

degrees were considered professionals, though this group could

have been stratified at least into those who hold an advanced

clinical/counseling degree versus those who hold only a bachelor's

degree. It is interesting that what the drug treatment field

134
labels professional counselors are often labeled paraprofessional

counselors in the mental health field (Durlak 1979, Nietzel and

Fisher 1981, Hattie et al. 1984). In all we are suggesting that

further studies in this area should analyze the interaction of

counselor groups with special types of clients and particular

therapy systems, based on a precise definition of the professional

counselor.

THE VOLUNTEER UTILIZATION STUDY

In the volunteer utilization study, we distinguished three groups

of volunteers: 1) specialized professionals such as physicians,

psychiatrists, and lawyers, 2) counselors, and 3) noncounseling

personnel, including administrative support staff. In this report

we address the specialized professionals and counselors as distinct resources in drug treatment programming. (See Aiken et al.

1981 for a more general report on all three volunteer groups.) We

begin with an overview of the prevalence of volunteers, based on a

national survey of programs. We then address the specialized

volunteers, their functions in the program, their services to paid

counselors, and their backgrounds. In a third section we consider

the volunteer counselors, with special emphasis on their direct

counseling services in the program and on their academic and

experiential preparation for their volunteer role. An evaluation

of volunteers by paid counselors is given. In a fourth section we

contrast the specialized professionals and counselors on a number

of issues--demographics and educational background, access to the

program, motivations for volunteering, length and amount of service to the program, sources of satisfaction with volunteering,

relationships with paid staff and clients, and participation in a

number of activities across a broad spectrum.

Method

Telephone survey: Phase I. All federally funded MM, TC, and DF

programs on the 1978 NDATUS file that listed five or more volunteers were screened for eligibility. They had to be single

modality programs, with at least five volunteers at the time of

the study. For the study, volunteers were defined as people who

work for no pay and for at least 1 hour per week in the program.

Students were included as long as they were not paid. Of the 138

eligible programs, telephone interviews were completed with the

administrators of 123, or 89 percent. In all there were 95 DF, 26

TC, and 2 MM programs.

On-site survey: Phase II. The telephone survey constituted Phase

I of the two-part study. Phase II involved on-site visits to

treatment programs. Of the 123 programs in Phase I, 9 DF and 6 TC

programs with substantial numbers of specialized volunteers and

nonspecialized volunteers, particularly counselors, were sitevisited. In all, 108 volunteers and 51 paid counselors were

interviewed across the programs.

135
Findings

Prevalence. Across the 123 programs lawyers were the most frequent specialized professional volunteers, and also the most

infrequent paid staff (see table 1). Volunteer psycholoqists,

nurses, and social workers were each found in more than 30 percent

of programs. Fully 80 percent of the 123 programs had volunteer

counselors, and 9 percent had no paid counselors. Hotline

counseling was essentially a volunteer function, with 95 percent

of programs with hotlines using only volunteers for that function.

Finally, more than half the programs depended on volunteers for

some administrative support services.

Programs often had large numbers of volunteers. Among the 123

programs, the median number was just under 25 (29 for DF, 14 for

TC), and a fourth of the programs had more than 50 volunteers.

Specialized professional volunteers. Approximately 80 percent of

the 123 programs had at least one specialized volunteer, with a

median of more than four per program. These specialized volunteers brought a high level of professional training and services

to programs that otherwise might not have these services.

The specialized volunteers did provide some direct services to

clients. However, the volunteers more often served the program

through consultant services to staff. They participated in inservice training of counselors, consulted with counselors about

the counselors' clients, and saw clients on a temporary basis at

the request of counselors. The specialized professionals also

provided administrative services--they served on Boards of

Trustees and helped develop policy and administer functions in

their own areas of expertise. Volunteer lawyers illustrate the

specialized professional function well. Of the 76 program

administrators with at least one volunteer lawyer, approximately

90 percent reported that the lawyers advised staff members about

legal issues concerning the program and/or the clients, and half

reported that the lawyers provided administrative and policy

support to the program as well.

The specialized professionals brought to the program more than

just their own services. Volunteers in every specialty procured

resources from the community for the program through referrals of

clients to resources outside the program, bringiny other specialists into the program, and obtaining funding.

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TABLE 1. Percentage of programs’ having paid staff and/or volunteers, by staff category

Staff Category

Programs With at Least Programs With Paid and/or

One Volunteer (Percent) Programs With at Volunteer Staff (Percent)

Least One Paid

All OF TC Staff Member Paid Volunteer

Program (N=95) (N=26) (Percent) Both Only Only Neither

Physician

Psychiatrist

Lawyer

Psychologist

Social worker (M.S.W)

Vocational counselor

Nurse

Counselors

Counselor with at least

bachelor's degree

Counselor without

bachelor's degree

Hotline worker

Administrative support staff

27.3 29.5 23.1

26.7 26.6 26.9

61.8 62.1 61.5

39.0 42.1 30.8

33.3 36.8 19.2

24.3 24.2 23.1

34.1 39.9 15.4

80.5 76.8 92.3

68.3 67.4 69.2

44.7 38.9 69.2

46.3 54.7 19.2

57.9 50.5 80.8

18.2 5.8 12.4 21.5 60.3

24.6 3.3 21.3 23.0 52.5

13.8 11.4 2.4 50.4 35.8

46.0 21.1 27.6 17.9 33.3

30.1 13.8 16.3 19.5 50.4

18.3 3.5 14.8 20.9 60.9

21.1 12.2 8.9 22.0 56.9

89.4 71.5 17.9 8.9 1.6

04.6 56.9 27.6 11.4 4.1

49.6 25.2 24.4 19.5 30.9

2.4 2.4

92.6 52.1

0.0 43.9

40.5 5.8

53.7

1.7

*N = 123; Includes two methadone maintenance programs.

SOURCE: Aiken, L.S.; LoSciuto, L.A.; and Ausetts, M. A Study of Volunteers in Drug Abuse Programs National Institute

on Drug Abuse Treatment Research Report. DHHS Pub. No. (ADM) 81-1147. Washington, D.C.: Supt. of Docs.,

Govt. Print. Off., 1981. p. 12.
Interviews with the 51 paid counselors in Phase II of the study

provided another perspective on the specialized volunteers, i.e.,

how they served paid staff. For all specialized categories except

vocational counselors, the paid counselors were more likely to

have requested information for use in working with a client than

to have requested aid in working with the client by having the

specialist see the client. The paid counselors almost universally

reported that their requests were met and that they were satisfied

or very satisfied with the specialists' responses.

The specialized volunteers (n = 31) interviewed in Phase II provided information on their current employment and work histories.

Overall, about 80 percent were currently employed in the

discipline in which they were volunteers. All the psychiatrists,

physicians, and lawyers had been employed in the professions in

which they were volunteering for a minimum of 3 years; and in half

the instances, more than 10 years. In contrast, half the psychologists, social workers, and vocational counselors had not been

practitioners in the professions in which they were volunteering,

though several were professors or teachers in their disciplines,

and several were students. Two-thirds of all specialized professionals volunteered for 5 or fewer hours per week. In contrast

with other volunteers, none of the specialized volunteers had ever

been in treatment for drug abuse.

Volunteer counselors . In all, 106 of the 123 programs of Phase I

had volunteer counselors; 11 had exclusively volunteer counselors.

All 106 programs provided in-service training and supervised the

volunteer counselors continuously. Most of the programs assigned

a staff member direct responsibility for the treatment provided by

volunteer counselors to their clients.

Phase II interviews with the 47 volunteer counselors provided

further information on their training and educational backgrounds,

caseloads, and drug use.

Of the 47 volunteer counselors, 45 percent held bachelor's

degrees. Almost half of these were psychology majors. Five held

master's degrees, three of them in clinical or counseling

psychology. Across all 47 volunteer counselors, fewer than half

had taken a counseling course. In all, 89 percent reported that

they had received training in counseling from the program in which

they were volunteering. Training of volunteer counselors was compared with that of all paid counselors of the paraprofessional

study. Volunteers had lower rates of having studied a large

number of treatment-related topics than had the paid counselors.

For example, fewer volunteers than paid counselors had studied

counseling techniques (74 percent versus 91 percent), specific

therapy methods (66 percent versus 83 percent), and client control

procedures (51 percent versus 70 percent).

In all, 11 percent of the volunteer counselors had held paid jobs

in drug abuse programs; four had worked as paid drug counselors.

138
Almost half had held some paid job in a service delivery program.

Considering all volunteer work experience, more than half had been

volunteer drug abuse counselors for less than 6 months (median =

5.7 months) with a median of 13 months for the aggregated length

of all volunteer counseling experience.

Volunteer counselors were asked to indicate for how many clients

they were the primary counselor, i.e., the "counselor who is

mainly responsible for the treatment regimen." More than 40 percent reported that they had no such clients, while 20 percent had

more than four clients each. In all, 77 percent of the counselors

counseled clients in individual counseling sessions. The counselors who provided any such counseling spent a median of 4 hours per

week doing so. Fewer counselors (45 percent in all) provided

group counseling; those who did spent almost 4 hours a week

(median = 3.7 hours) doing so. Phase I reports were similar, in

that 26 percent of the 123 programs let volunteers serve as primary counselors, 34 percent only as auxiliary counselors, and the

remainder, as a mixture of both.

Volunteer counselors of Phase II also were involved in other

counseling-related tasks such as filling out forms dealing with

clients (75 percent of volunteer counselors involved), learning

about community resource agencies that might serve their clients

(81 percent), discussing clients in staff meetings (66 percent),

and doing hotline counseling (57 percent). They had lower rates

of involvement in client-related activities that took them out of

the program, such as working with clients in the community (30

percent), providing personal aid to clients (29 percent), and

providing social activities for clients (32 percent).

In the Phase I study, 14 of the 123 programs drew all their volunteers from among their own clients. In all, 15 percent of the

volunteer counselors in the Phase II study had been drug addicts;

in most individual drug use categories, volunteer counselors

reported lower use than did paid counselors.

The views of administrators on the drug-use history of their counselors was explored. Of the 123 administrators of Phase 1, only 5

percent thought that volunteers should have no history of drug use

or drug treatment. The remainder were approximately evenly

divided as to whether a drug use history helped volunteers understand drug problems or whether it merely did not interfere with

their work in the program.

Paid counselors' evaluations of volunteers suggested there might

be tension between the two groups. Paid counselors in Phase II

evaluated volunteer counselors' characteristics relative to their

own, indicating that they were less knowledgeable about drugs than

are paid counselors (72 percent), less able to take responsibility

(47 percent), and less dedicated to the program mission (45

percent). Their judgments concerning volunteers' ability to take

over certain activities entirely were negatively correlated with

139
the centrality of the activity to the paid counselors' role. In

all, 71 percent of Phase II counselors thought volunteer counselors could take over providing social activities, and 68 percent

thought that volunteers could take over reviewing community

resource agencies for clients, in contrast with 29 percent who

thought that volunteers could take over individual and 25 percent,

group, counseling.

Administrators agreed with paid counselors that the volunteer

counselors were less knowledgeable about drugs (70 percent). The

administrators also indicated that volunteer counselors were less

well educated (63 percent), and had less relevant educations (42

percent) and work experience (68 percent) than paid counselors.

Contrasts between specialized professionals and counselors. Phase

II interviews with specialized professional volunteers versus

volunteer counselors showed these groups to be distinct in a

number of areas including demographics, access to the program,

motivations for volunteering, length and amount of service to the

program, their sources of satisfaction with the volunteer experience, and finally, their perceptions of relationships between paid

staff, volunteers, and clients.

Specialized volunteers were established professionals most often

holding terminal degrees in their disciplines, i.e., M.S.W. for

the social workers, Ph.D. for the psychologists, B.S. for the

nurse, and of course, M.D. and J.D. for the doctors and lawyers.

Only 3 of the 31 were students. Their modal age category was between 41 and 50, and 55 percent were married. Their median annual

income was 835,000. None considered themselves ex-addicts. It

will be recalled that in contrast, two-thirds of the volunteer

counselors of Phase II were students, and more than 40 percent did

not hold bachelor's degrees; only 10 percent held master's

degrees. The age distribution of the counselors was bimodal, with

(modes in the age categories 22-25 and 36-40; only a third were

married. Only half were currently employed, with a median annual

income of 812,500. In all, 15 percent considered themselves exaddicts. Finally, both groups were predominantly Caucasian (87

percent of the specialized volunteers and 94 percent of the

counselors).

Specialized professionals first learned that the program needed

volunteers through friends (42 percent) or people in the program

(26 percent), while counselors more often learned from their own

experience with the program (26 percent) or through school (30

percent). While 48 percent of specialized volunteers were contacted by the program to ask them to volunteer, this was true for

only 11 percent of volunteer counselors.

Thirty-two percent of the counselors as opposed to 3 percent of

the specialized professionals reported that they chose to volunteer in drug programs due to their own experience with drugs or

that of their friends. Counselors (73 percent) more often than

140
professionals (50 percent) reported a desire to learn, the gaining

of experience for future jobs (54 percent versus 17 percent), and

school program requirements (19 percent versus 3 percent) as

reasons for volunteering; specialists more often mentioned the

development of professional contacts (13 percent versus none for

counselors). Both groups emphasized the desire to help people

with a social problem (82 percent of counselors and 87 percent of

professionals).

The specialized professionals and counselors had very different

patterns of volunteering. A third of the professionals had

volunteered at their current program for 5 or more years

(median = 34 months), while 45 percent of counselors had been at

the current programs for 6 months or less (median = 70 months).

There was a smaller group of counselors (15 percent) who had been

volunteers for 5 or more years.

In contrast with length of service, counselors spent substantially

more time in the program per week than did professionals. Twothirds of professionals spent 5 or fewer hours per week in the

program (median = 3 hours), while three-quarters of the volunteer

counselors spent 10 or more hours per week in the program

(median = 12 hours).

Of the specialized professionals, 73 percent, versus 47 percent of

the counselors, intended to remain volunteers in the program. In

contrast, a third of counselors, but only 10 percent of the

specialized volunteers, intended to leave within 6 months.

All members of both volunteer groups reported that they were satisfied with their volunteer experiences. In response to an openended question concerning reasons for satisfaction, a third of

each group gave fulfillment through volunteering and enjoyment of

working with people as reasons; a quarter of each group mentioned

putting their skills to work. However, 43 percent of counselors

versus 13 percent of professionals mentioned the opportunity to

learn as a reason for satisfaction; and 23 percent of the counselors versus 3 percent of the professionals mentioned being

treated with respect.

Asked what would make them more satisfied as volunteers, more

counselors endorsed areas of improvement of the volunteer situation than did administrators: more responsibility (28 percent of

counselors versus 10 percent of professionals), more important

tasks to perform (28 percent versus 3 percent), better working

conditions (21 percent versus 10 percent), and more direct contact

with clients (36 percent versus 13 percent). Counselors indicated

that having more direct contact with clients was the single factor

that would be most important to their increased satisfaction.

Volunteers were asked to compare themselves with paid staff along

a numher of dimensions. In all, 28 percent of professionals

versus 2 percent of counselors reported they had more authority

141
than paid staff; 25 percent of professionals versus 42 percent of

counselors, less authority. Both professionals and counselors,

however, saw themselves as less well-respected by clients (75

percent of professionals and 91 percent of counselors) and less

well-respected by administrators (85 percent of professionals and

93 percent of counselors) than were paid staff. In contrast, both

groups thought that they were accepted by administrators, clients,

and paid counselors as being useful in the program.

DISCUSSION

It appears that the specialized volunteers and volunteer counselors ought to be treated quite distinctly from the perspectives

of recruitment and administration. The specialized volunteers in

this study were established professionals, often of long-standing

in the field, whose motivations for volunteering and whose satisfactions with volunteering are captured by traditional notions of

altruism and service to society. They had often served the programs for long years and intended to continue to serve. They

provided highly technical support to the counseling staff and

brought community resources to the program. They provided the

program with specialized expertise which would not have been

available to the programs in their absence. These specialized

volunteers, due to their seniority, their encapsulated roles in

the program, and the stability of their volunteer efforts over

time, likely posed a minimal administrative burden to the program.

In our sample, half the specialized volunteers were first

contacted by the programs. The volunteer professionals most

frequently indicated that they had heard of the program's need for

volunteers through friends or family members. This suggests that

paid program staff would be important recruiting agents for the

program, and that personal appeals on a one-to-one basis would be

useful. The demographics of the professionals in our sample

suggest that the targets of recruitment ought to be older, wellestablished individuals.

In the main, volunteer counselors in our study were a substantially different group, often students, volunteering for relatively limited periods of time with training goals in mind. A

substantial number had used drugs, and a portion were ex-addicts.

In actuality, there appeared to be a small subgroup of volunteer

counselors also who resembled the specialized professionals--

older, having volunteered for longer time periods, intending to

stay in the program, and with motivations and satisfactions that

mirrored those of the specialized professionals.

Considering the bulk of the volunteer counselors in the study, one

might well prescribe recruitment through universities, through

systematically established relationships with graduate counseling

programs that require internship experiences. Because such programs will not likely be directed toward the treatment of drug

addiction per se, there will be a heavy burden on programs to

142
provide inservice training on issues of drug abuse and drug

treatment. Further, there will be an administrative commitment

required for the smooth functioning of a relatively transient

population of young adults who are delivering primary care on a

voluntary basis.

Further Research

Through 1980, the NDATUS report gave staffing information by specialization for volunteers as well as paid staff. The staffing

categories were continued from prior years with little

modification. In 1982, reporting changed. Volunteers were

stratified into only two categories, "direct care staff" and

"administrative or support staff." The stratification that we

have found useful here, i.e., into volunteer counselors and

specialized volunteers, cannot be recovered from this dual-level

categorization. The 1984 NDATUS, as it is now planned, is a

program census--no staffing information whatever will be gathered

(Blanken 1984). Hence any information on the order of magnitude

of the volunteer effort in drug treatment will be lost. Any documentation of the growth versus decline of volunteer utilization

will now fall to researchers in the field.

We have a suggestion. In 1982 the NDATUS report gave fulltime

equivalent volunteers, not headcounts. Headcounts are needed for

an understanding of the order of magnitude of the volunteer

effort. To say that 62 percent of the 123 federally funded programs we surveyed had a volunteer lawyer provides a very different

picture from saying that there were approximately 6.5 fulltime

equivalent volunteer lawyers across the 123 programs (35 hours per

week; 3 hours per week on average per specialized volunteer; 76

volunteer lawyers).

The budgetary issue of cost-effectiveness of volunteer use must be

confronted. It is our hypothesis that the use of specialized

volunteers is a cost-effective enterprise. The same might well

hold for that subset of volunteer counselors who are like the

specialized volunteers, i.e., established professionals in their

own right, who serve as volunteers over long periods of time, and

become integrated into the program staff. Students serving as

volunteer counselors as part of internship programs may be quite

another matter. The administrative cost of training and supervising these volunteers is likely substantial. All this, however, is

conjecture at the present time. An understanding of the costs

associated with volunteer use is essential before broad policy on

volunteer use can be developed and budgetary planning that incorporates them can occur.

In the present study, it is reasonable to conceptualize paid

counselors as the clients of the specialized professional

volunteers. The paid counselors used the specialized volunteers

as consultants, and reported on their satisfaction with the services they received. It is unlikely that the drug field per se

143
will wish to open the issue of whether these medical, psychiatric,

and legal services are of high technical quality. Barring this

excursion into evaluation of the quality of professional services,

this study provides evidence as to the high level of satisfaction

of the counselors with the consultant services provided by the

specialized volunteers.

The evaluation of services provided by volunteer counselors based

on clients outcomes remains to be undertaken. The work from our

study of paraprofessional counselors provides a model of how such

an evaluation might be performed. It is worrisome to note that

all but a very few volunteer counselors reported that they were

less well-respected by clients than are paid staff who did the

same work. If clients devalue the services of volunteer

counselors, then what can be the impact of volunteer counseling on

client progress in treatment? We think this may be the most

critical question to face in formulating policy on the use of

volunteer counselors in drug treatment. It is all well and good

to say that in times of restricted funding, the field can turn to

volunteers. But we need to know how well those volunteers provide

the services the field depends upon them to provide.

REFERENCES

Aiken, L.S., and LoSciuto, L.A. Ex-addict versus nonaddict

counselors' knowledge of clients' drug use. Int J Addict, in

press.

Aiken, L.S.; LoSciuto, L.A.; and Ausetts, M.A. A Study of Volunteers in Drug Abuse Programs. National Institute on Drug Abuse

Treatment Research Report. DHHS Pub. No. (ADM) 81-1147.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off.,

1981. 18 pp.

Aiken, L.S.; LoSciuto, L.A.; Ausetts, M.A.; and Brown, B.S.

Paraprofessional versus professional drug counselors: Diverse

routes to the same role. Int J Addict 19(2):153-173, 1984a.

Aiken, L.S.; LoSciuto, L.A.; Ausetts, M.A.; and Brown, B.S. M.A.

paraprofessional versus professional drug counselors: The

progress of clients in treatment. Int J Addict 19(4):383-401,

1984b.

Ausetts, M.A.; LoSciuto, L.A.; and Aiken, L.S. The Use of

Volunteers in Drug Abuse Services: A Review of the Literature.

National Institute on Drug Abuse Services Research Report. DHHS

Pub. No. (ADM) 80-1020. Washington, D.C.: Supt. of Docs., U.S.

Govt. Print. Off., 1980. 110 pp.

Blanken, Ann. Personal communications, 1984.

Brown, B.S., and Thompson, R.F. The effectiveness of formerly

addicted and nonaddicted counselors on client functioning.

Forum 5(2):123-129, 1976.

Drug

Cohen, J. Statistical Power Analysis for the Behavioral Sciences.

New York: Academic Press, 1977. 474 pp.

Connett, G.E. Comparison of progress of patients with professional and paraprofessional counselors in a methadone

maintenance program. Int J Addict 15(4):585-589, 1980.

144
Cook, T.J., and Scioli, F.P., Jr. The Effectiveness of Volunteer

Programs in Courts and Corrections: An Evaluation Policy

Related Research Chicago: University of Illinois at Chicago

Circle, 1975.

Durlak, J.A. Comparative effectiveness of paraprofessional and

professional helpers. Psycho1 Bull 86(1):80-92, 1979.

Hattie, J.A.; Sharpley, C.F.; and Rogers, H.J. Comparative effectiveness of professional and paraprofessional helpers. Psycho1

Bull 95(3):534-542. 1984.

Longwell, B.; Miller; J.; and Nichols, A.W. Counselor effectiveness in a methadone maintenance program. Int J Addict

13(2):307-315, 1978.

LoSciuto, L.; Aiken, L.S.; Ausetts, M.A.; and Brown, B.S. Paraprofessional versus professional drug abuse counselors:

Attitudes and expectations of the counselors and their clients.

Int J Addict 19(3):233-252, 1984.

National Institute on Drug Abuse. Executive Report, April, 1978:

Data from the National Drug Abuse Treatment Utilization Survey.

(NDATUS). Statistical Series, Series F, Number 5, Rockville,

M.D.: the Institute, 1978.

National Institute on Drug Abuse. Final Report, September, 1980:

Data from the National Drug and Alcoholism

Survey(NDATUS). Statistical Series, Series F, Number 9,

Rockville, M.D.: the Institute, 1980.

National Institute on Drug Abuse.

Treatment Units, September, 1982: Data from the National Drug

Main Findings for Drug Abuse

and Alcoholism Treatment Utilization Survey (NDATUS).

Statistical Series, Series F, Number 10, Rockville, M.D.: the

Institute, 1982. 69 pp.

Nietzel, M.T., and Fisher, S.G. Effectiveness of professional and

paraprofessional helpers: A comment on Durlak. Psycho1 Bull

89(3):555-565, 1981.

Ottomanelli, G.A. Patient improvement measured by the MMPI and

Pyp, related to paraprofessional and professional counselor

assignment. Int J Addict 13(3):503-507, 1978.

Smith, D.H. Research and communication needs in voluntary action.

In: Cull, J.G., and Hardy, R.E., eds. Volunteerism: An

Emerging Profession. Springfield, Ill.: Thomas, 1974. pp.

111-186.

Suarez, M.L., and Ricketson, M.A. Facilitating casework with

protective service clients through the use of volunteers. Child

Welfare 53(5):312-322, 1974.

AUTHORS

Leona S. Aiken, Ph.D.

Leonard A. LoSciuto, Ph.D.

Mary Anne Ausetts, M.A.

Institute for Survey Research

Temple University

Philadelphia, PA 19122

145

THE HARVARD GROUP AFTERCARE

PROGRAM: PRELIMINARY

EVALUATION RESULTS AND

IMPLEMENTATION ISSUES

William E. McAuliffe,

James M.N. Ch’ien, Elaine Launer,

Rob Friedman, Barry Feldman

INTRODUCTION

This paper describes preliminary results from a 4-year crosscultural demonstration and evaluation of a group aftercare program

for successfully treated opiate addicts. The program combines

both professional and self-help approaches. The professional component features a comprehensive 6-month training curriculum that

systematically addresses the major causes of relapse and obstacles

to full recovery. The self-help component uses fellowship meetings to provide support and role modeling to motivate and sustain

behavior change. The evaluation was a randomized clinical trial,

with sites in Boston and Worcester, Massachusetts; Providence,

Rhode Island; and Hong Kong. At each site, the study team recruited, interviewed, and randomly assigned treated addicts to

either our aftercare program or a "usual-care" control condition.

After an average of 9 and 20 months, the researchers reinterviewed

subjects to assess their outcomes. The study sought to determine

whether participation in the aftercare program could prevent

relapse and antisocial behavior while facilitating social

reintegration. We will describe our program in more detail and

review previous research, describe our research methodology and

results, review implementation issues, and summarize our

conclusions.

PROGRAM DESCRIPTION

Our Boston group illustrates how our aftercare program borrows

from both self-help and professional traditions. The group met

twice weekly. One meeting was a training session led by a professional group worker and open to members and guests; the other,

a self-help session led by an ex-addict, was open to members only.

Other groups met once a week, with the time split between a

training and a self-help segment. The groups were professionally

initiated, and usually included from 8 to 12 members. Guests

sometimes increased training session attendance to 25.

147
The professionally led meetings were based on a health

promotion/education model rather than a psychotherapeutic model.

Led by master's-level social workers and psychologists, these

training sessions were highly structured and adhered to a planned

6-month curriculum. The curriculum was designed to address systematically each of the major threats to ex-addicts' recovery. We

identified these threats from studies of relapse and from our

clinical experience. Topics included recovery phases, deaddiction

and craving, avoidance of active addicts, employment, love and

intimate relations, stress reduction, new friendships, pain and

prescription medicine, nonopiate substance abuse, and fun without

drugs. We researched each of these topics, and prepared materials

and exercises that would help leaders make and reinforce the

sessions' key points. We have collected these materials into a

training handbook (Zackon et al. 1984) for others who wish to

develop similar programs.

The self-help sessions featured individual sharing and support for

recovery and reintegration, recovery stories by peer leaders and

other long-term ex-addict associates, and planning of recreational

and community service activities. Because makiny new friends and

finding nondrug social activities are major problems for recovering addicts, we encouraged members to socialize with one another

outside of formal meetings. Groups had parties, cookouts, soccer

matches, softball games, and various outings. In addition, we

encouraged members to identify themselves as ex-addicts in daily

socializing and by performing public service.

PREVIOUS EVALUATION RESEARCH

Because Brown and Ashery (1979) and Nurco et al. (1983) nave ably

reviewed the general topic of aftercare in drug abuse programming

and because another paper in this volume (Catalano) addresses

skills training in aftercare, we will confine ourselves to reviewing previous evaluative research directly relevant to our program.

Credit for the concept of combining self-help and professional

approaches to addict aftercare goes to James Ch'ien, who formed a

group of ex-addicts in Hong Kong in 1968. Ch'ien (1979) evaluated

his approach by comparing 100 persons who participated in the

aftercare program with 100 ex-addicts who did not participate.

After 2 years, 57 percent of the aftercare subjects were abstinent compared to only 9 percent of the control group. Because

the internal validity of a nonrandomized study may be threatened

by the possibility of selection bias--that is, aftercare clients

may have been more motivated to recover than comparison group

members--our randomized study was undertaken.

While we at the Harvard School of Public Health were proposiny the

present study, Nurco et al. (1983) began a demonstration project

designed to show that self-help aftercare groups for ex-addicts

could he initiated with the help and sponsorship of drug treatment

professionals. Nurco et al.'s groups differed from ours in two

major ways: they had no preplanned training curriculum, and in

148
their groups the professionals withdrew as soon as the groups were

strong enough to survive on their own. Despite these differences,

the descriptive data collected by Nurco et al. and the conclusions

they reached about self-help groups for ex-addicts were confirmed

by our experiences.

To our knowledge, no previous researchers have conducted a randomized evaluation of aftercare for opiate addicts or specifically of

self-help groups for ex-addicts. We undertook this task because

we thought that our program and the self-help movement as a whole

were being held back by the lack of sound evidence on efficacy.

What follows is a description of our methods and results.

RESEARCH METHODOLOGY

The Sample

The results presented in this article are from the study's first

144 subjects (80 from Hong Kong and 64 from the United States

recruited between 1979 and 1982). Because our subjects were drawn

from two different countries, it is natural that two distinct

populations are represented. Also, because our populations volunteered for aftercare. they are a unique subset of the population

of addicts in treatment. The subjects averaged 31 years of age;

were 85 percent male; the Hong Kong subjects were 100 percent

ethnic Chinese, the American subjects were 95 percent Caucasian

and 5 percent black; the Americans were two-thirds Catholic, while

the Chinese were 87 percent without religious preference. In

addition, the Americans were better educated; more often employed,

with higher occupational prestige; and more likely to be married

than the Chinese were. All of the subjects were opiate addicts

(addicted for a mean of 6.4 years) and had relapsed an average of

4.3 times prior to entering the study.

The American subjects came mostly from methadone maintenance programs (62 percent), outpatient drug-free counseling (14 percent),

and detoxification programs (11 percent); the Chinese came from

halfway houses (50 percent) or Shek Kwu Chau (50 percent), Hong

Kong's island residential treatment center. During the month

before entering the program, 82 percent did not use illicit

opiates, and 18 percent used an illicit opiate at least once.

Randomization and Followup

The 144 subjects were randomized to treatment (77) or control (67)

conditions at the study's six yroup sites. Control subjects were

urged to make use of aftercare services available to them as part

of the primary treatment program from which they were referred or

other availahle community resources. Followup interviews were

scheduled for 6 and 12 months after the baseline interview.

Ninety-eight percent of the first followups and 82 percent of the

second followups were completed, although it took an average of

9.1 months and 19.7 months respectively to complete them. Subject

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attrition at second followup was due to refusal and nonresponse (4

percent), death (3 percent), relocation (1 percent), and subjects

who were not reinterviewed because of practical administrative

problems (10 percent). All significance levels reported in this

article are from two-tailed tests.

RESULTS

Process Evaluations

Although the meat of our evaluation was an assessment of outcomes,

including illicit opiate use, employment, and crime, this section

presents the results for several key process measures. They are

1) length of membership in the groups, 2) participation in group

activities, and 3) the subjects' own assessments of the programs'

value.

About half of the subjects were active group members for about 13

weeks (approximately 3 months), and a quarter were members for 6

months or more. In the United States during the project's fourth

year (not reported here), the number of dropouts declined dramatically after we adopted a mandatory 3-week attendance period before

subjects were randomized. Of the last 16 experimental subjects,

69 percent remained the entire 6 months. Two of the American

groups are still active and self-sustaining 7 months after the

research was discontinued.

Treatment and control groups were compared in four dimensions of

activities that characterize our program's self-help component

(learning about recovery, socializing with recovered addicts,

trying to help others recover, and social service), and two that

do not (working in a treatment program and religious activities).

In each of the four dimensions characterizing our program, the

differences favored the treatment group for both first and second

followup, and by the second followup all of the differences were

significant. By contrast, the other two activities were not different across experimental and control groups. A subsample of the

experimental subjects were asked whether being in the study had

helped them. At the first followup, 74 percent said that it had

helped to some degree; at the second followup, 87 percent said so.

Thus, there was clear evidence that we were able to implement the

treatment: subjects attended meetings and participated in selfhelp activities, and most participants thought that the program

was helpful.

Relapses During a 1-Year Followup Period

The most important objective of our aftercare program was to prevent readdiction to illicit opiates. During the first 6-month

followup period, 46 percent of the combined sample had relapsed

(10 or more days of daily use); during the second 6-month period,

more than 60 percent relapsed. However, for both 6-month periods,

150
the experimental group had significantly more subjects who had

good outcomes, defined as abstinent or having only rare "slips"

(use less than once per month). After statistical controls for

baseline differences and country effects were introduced, the

combined experimental groups had more subjects with good outcome

than the control groups did (32 percent versus 18 percent) for the

entire 12-month followup period (p < .05). Thus, as a result of

aftercare, the experimental group's rate of positive outcomes was

77 percent better than the control group's.

When we examined the countries separately, we found that in Hong

Kong 15 percent more of the experimental subjects had positive

outcomes than the controls throughout both 6-month time periods,

which is at the .1O confidence level. In the United States 17

percent more of the experimental group than the controls had positive outcomes, which is at the .18 confidence level. The effect

in the United States appeared to weaken over time, since it was

significant at the .05 level for the first 6 months but significant only at the .1O level for the second 6 months, and at the .18

level for the entire year. The small differences in the treatment

effect across countries were not statistically significant for any

time period.

A quantitative measure of this outcome is the number of days on

which the subjects used an illicit opiate during the 12 months. A

regression analysis of this measure found that the combined

experimental group used illicit opiates on 49 fewer days than the

control group did, an effect that was significant at the .O1

level. The effect in Hong Kong was 59 days (p < .05), and in the

United States the effect was 37 days (p < .12).

Space prevents presentation of the several other measures of

relapse we obtained in this study, including measures of legal

methadone use. The conclusions in each case were basically the

Same: there is a significant positive treatment effect for both

the first and second followup periods when the combined sample is

employed. Although the treatment effects are in the right direction in both Hong Kong and the United States, the small sample

size, especially in the United States, often makes it difficult

for these effects to achieve significance. For most of these

opiate-use measures, the treatment effects were greater in Hong

Kong than in the United States, but the differences between countries (interactions) were not significant. Finally, in Hong Kong

the effect remained virtually constant throughout the followup

period, but in the United States it appeared to fade somewhat

after the first 6 months. One possible explanation for this difference is that after a 1-year period the Chinese subjects could

join the 1,500-member self-help organization of ex-addicts in Hong

Kong, whereas no such parent organization existed in the United

States.

151
Employment

Although employment is a key outcome measure for almost any opiate

drug treatment program, it is somewhat less central for our aftercare program because a majority of our subjects in the United

States had jobs or were effectively out of the labor force

(mothers with several small children) when they joined the groups,

and a majority of addicts in Hong Kong work even when they are

actively addicted. Our program's employment objectives vary.

Depending on the subject's employment status at entry, the

objective is 1) to help the unemployed find jobs or 2) to prevent

job loss and improve careers of the employed.

Our results show that the experimental group members had better

employment outcomes than the controls at 6 and 12 months, but the

effect is significant only at 12 months for the combined United

States and Hong Kong sample. At 12 months 65 percent of the

combined experimental group were employed, compared to 46 percent

of the combined control group. When we examined the number of

months employed during the year-long followup period, the differences between experimental and control yroups were favorable, but

not significant.

Almost all of the employment treatment effect was in helping

unemployed subjects find jobs. Relatively few of the initially

employed subjects, either experimental or controls, lost their

jobs, and the experimental condition made no apparent difference.

By contrast, for initially unemployed outpatients (N=39) there

were large, significant differences in employment rates between

experimental and control groups at 6 months (61 percent vs. 30

percent) and 12 months (64 percent vs. 18 percent), and for initially unemployed inpatients (N=40) there was a significant

difference (75 percent vs. 35 percent) between the experimental

and control subjects at 12 months. The difference in treatment

effect between the initially employed and unemployed outpatients

was statistically significant. This pattern of results was

repeated when we examined the number of months of fulltime employment during the year, with the treatment effect for initially

employed subjects significant at the .05 level duriny the second

6-month period in the combined sample and the United States

sample.

Thus, the aftercare program had significantly positive effects on

helping unemployed subjects find and keep jobs, especially during

the second 6 months followiny baseline.

Criminality

The usual indicators of criminality, such as arrest or incarceration, did not occur with great frequency in this population during

the entire followup period (15 months in the United States and 22

months in Hong Kong) and revealed no significant differences between treatment and control. However, in examining self-reported

152
criminality, we found that the Hong Kong experimental group had

significantly fewer members with indications of criminality than

the control group did (49 percent vs. 79 percent) during the

second followup period. The effect in the United States was in

the right direction (58 percent vs. 77 percent) but not significant during the first followup period, and it virtually

disappeared (67 percent vs. 72 percent) by the end of the second

followup period.

DISCUSSION

In sum, the research showed that our mixed self-help and professional aftercare program was implemented satisfactorily in both

Hong Kong and the United States. The program was received

favorably by the subjects themselves, and it had statistically

significant effects on preventing relapse and getting unemployed

ex-addicts back to work. It also significantly reduced selfreported crime in Hong Kong and reduced crime in the United

States, but not enough to be statistically significant.

Implementation Issues

Since many of the usual questions about initiating our program and

handling a group once underway have been addressed elsewhere by

Nurco et al. (1981) and by ourselves (Zackon et al. 1984), we will

confine our discussion in this article to a few broad implementation issues.

Starting our groups was hard. The greatest amounts of effort were

required in developing a suitable structure and curriculum materials, getting real support from referral sources, getting members

to participate fully, maintaining regular attendance, and preventiny attrition. Because our handbook provides a proven structure

and curriculum materials, the major problems for a new group will

be finding enough interested and appropriate clients and hiring

leaders who will faithfully implement the model and keep members

participating in the program long enough and actively enough to

reap its benefits.

Although we believe that the training and the self-help structure

ultimately set this program apart from other aftercare groups,

starting the group requires leaders with skill, energy, charisma,

patience, and time. The professional may need to work almost

fulltime for a month or two to get the ball rolling. Once the

group is established, the professional and peer leader are needed

for 8 to 10 hours per week. The budget for one of our freestanding groups is now approximately $20,000 per year for the

yroup leaders and incidentals. An agency-based program is

estimated to cost $12,000 per year. The estimated weekly time is

10 hours for a professional and 5 hours for a peer leader.

Our experience suggests that this program could flourish in a wide

range of treatment settings. Our subjects were opiate addicts

153
drawn from the full gamut of treatment modalities (methadone,

therapeutic community, inpatient detoxification, and outpatient

drug-free). We worked as a freestanding agency in the United

States and as part of a large drug-treatment agency in Hong Kong.

We see no reason why the curriculum and self-help structure could

not be adapted to other drugs, for the issues faced by recovering

persons are often similar regardless of the drug abused. Our own

future research is most likely to be on adapting the program for

ex-cocaine addicts. We already have one program that has begun to

use our materials with slight modification for a methadone detoxification group and a cocaine addict group, and in Hong Kong the

model is being used in primary treatment as well as aftercare.

Extension to primary care is another topic for future research.

At present we encourage individual clients to use other services

when needed, especially individual counseling for obvious psychological problems and Narcotics Anonymous (NA) for additional

support and inspiration, especially during crises. Clients often

have such needs, but undue attention to them can prevent an aftercare group from addressing less urgent but equally important recovery issues that are not dealt with elsewhere. One group member

said, "NA is my commitment, this group is my growth." Moreover,

when compared to programs that focus on primary treatment or both

primary treatment and aftercare, our program offers a unique

opportunity for new members to be surrounded by success, not

failure. Our admission policies and program structure ensure that

members, peer leaders, and ex-addict associates form a community

in which abstinence and community reintegration are the norms.

CONCLUSIONS

Finally, we want to briefly review the theoretical issues in drug

treatment that this research addresses. We think we have shown

that relapse rates can be reduced by an aftercare program that

goes beyond the services currently available to ex-addicts. We

believe that the benefits of the program will increase even

further with its development and refinement.

The program's success demonstrates that professional and self-help

approaches can be combined effectively to take advantage of the

strengths of each. Although our outcome measures do not allow us

to separate the effects of self-help from the training sessions,

the addicts themselves made clear the importance they attached to

the program's self-help elements. In addition, we have shown that

self-help programs can be rigorously evaluated using random

assignment to treatment. Our positive results, even if not as

impressive as previous findings from Ch'ien's (1979) nonrandomized

evaluation, are a springboard for continued development.

Our 6-month curriculum exemplifies our conscious divergence from

the usual psychotherapeutic model of drug treatment and aftercare

(Brown and Ashery 1979). We favor a structured, systematic regimen that draws from research and clinical knowledge. Our proyram

154
also emphasized a hands-on, activist approach that goes beyond the

therapist's office and formal group meetings. Information, planning, models, motivation, and support are our therapeutic agents.

We believe that our results show this approach is cost-effective

and appealing to ex-addicts.

REFERENCES

Brown, B.S., and Ashery, R.A. Aftercare in drug abuse programming. In: DuPont, R.I.; Goldstein, A.; and O'Donnell, J.,

eds. Handbook on Drug Abuse. National Institute on Drug Abuse.

Washington, D.C.:- Supt. of Docs., U.S. Govt. Print. Off.,

1979. pp. 165-173.

Ch'ien, J.M.N. Alumni associations in Hong Kong. In: Brown,

B.S., ed. Addicts and Aftercare:

Former Drug User. Beverly Hills: Sage, 1979. pp. 155-163.

Community Integration of the

Nurco, D.N.; Stephenson, P.; and Naesea, L. Manual for Setting Up

Drug Abuse Treatment Research Report. DHHS. Pub. No. (ADM)

Self-He1p Groups of Ex-Narcotic Addicts. National Institute On 

81-1087. Washington, D.C.: Supt. of Docs., U.S. Govt. Print.

Off., 1981. pp. 1-23.

Nurco, D.N.; Wegner, N.; Stephenson, P.; Makofsky, A.; and

Shaffer, J.W. Ex-Addicts' Self-Help Groups. New York:

Praeger, 1983. 177 pp.

Zackon, F.; McAuliffe, W.E.; and Ch'ien, J.M.N. Addict Aftercare:

Recovery Training and Self Help. National Institute on Drug

Abuse. DHHS Pub. No. (ADM) 85-1341. Washington, D.C.: Supt.

of Docs., U.S. Govt. Print. Off., 1984.

AUTHORS

William E. McAuliffe, Ph.D.

Elaine Launer, B.A.

Rob Friedman, M.A.

Barry Feldman, B.S.

Department of Behavioral Sciences

Harvard University School of

Public Health

677 Huntington Avenue

Boston, MA 02115

James M.N. Ch'ien, M.S.W., M.P.H., S.A.R.D.A.

Duke of Windsor Social Service Building

15 Hennessy Road, Third Floor

Hong Kong

155

PROJECT SKILLS: PRELIMINARY

RESULTS FROM A THEORETICALLY

BASED AFTERCARE EXPERIMENT

Richard F. Catalano, J. David Hawkins

Drug abuse treatment seeks to achieve three broad goals: 1) the

cessation of illicit drug use and criminal activity, 2) the

establishment of socially acceptable behavior patterns, including

legitimate employment, maintenance of a basic standard of living

without recourse to welfare or crime, the development and

maintenance of a stable set of relationships with family and

friends, and 3) the prevention of a return to drug use and crime.

Historically, drug treatment programs have focused predominantly

upon the first and second goals. Different programs have

emphasized various aspects of the goal of establishing socially

acceptable behavior patterns. In contrast, the third goal,

prevention of a return to drug use and criminal activity following

treatment, has received relatively little attention in drug abuse

treatment programs (Hawkins 1979, Smart 1976). Strategies for

preventing and coping with relapse generally are not well

developed components of drug treatment programs.

It is not surprising that stopping illicit drug use and crime are

the focus of drug treatment. Currently, most State and local

policies provide resources for drug treatment when people are most

dysfunctional and threatening to themselves or others. Few

resources are earmarked for treatment maintenance services. Nor

is it surprising, in this situation, that treatment is often a

revolving door through which drug abusers periodically recycle

(Hawkins and Catalano in press).

A concern with maintaining the gains made in treatment has focused

interest on aftercare. The fundamental goal of aftercare in drug

abuse treatment is to prevent treated drug abusers from returning

to drug abuse. As an intervention, aftercare is based on the

assumption that continuing assistance following treatment can

remove or reduce post-treatment factors associated with relapse

and strengthen those factors associated with the maintenance of

sobriety. The concept of aftercare has come to encompass those

efforts to ensure that the former client can successfully maintain

157
a life free from drug dependence in the larger community following

treatment (Brown and Ashery 1979).

FACTORS RELATED TO RELAPSE

The prevention of relapse to drug abuse through aftercare initiatives requires an understanding of the factors that inhibit

relapse. A number of these factors have been identified. They

include: pretreatment client characteristics, in-treatment

adjustment, the modality of treatment and post-treatment experiences (Costello 1980, Finney et al. 1980, Goldstein and Kanfer

1979, Hawkins and Fraser, in press, Levy 1972, Simpson and Sells

1982. Stead and Viders 1979). Aftercare efforts address the posttreatment factors associated with a return to drug use.

Elsewhere we have reviewed the post-treatment factors that appear

to be related to relapse following treatment for either drug or

alcohol abuse (Hawkins and Catalano, in press). These factors

include absence of a strong prosocial interpersonal network,

including family and friends (Finney et al. 1980, Levy 1972,

Moberg et al. 1982, Moos et al. 1979, Stanton 1978, Stanton and

Todd 1979, Waldorf and Biernacki 1981), pressure to use drugs from

drug-using peers and family (Harbin and Mazier 1975, Hawkins 1979,

Hawkins and Fraser, in press, Hejinian and Pittel 1978, Krohn et

al. 1980, Marlatt and Gordon 1980, Stanton et al. 1978, Wellisch

and Kaufman 1975). isolation (Hawkins 1979, Stead and Viders

1979), lack of productive work or school roles (Savage and Simpson

1979, Simpson 1981, Simpson and Lloyd 1979, Waldorf and Biernacki

1982), lack of involvement in active leisure or recreational

activities (Finney et al. 1980, Moberg et al. 1982, Moos et al.

1979, Simpson 1981, Stead and Viders 1979), negative emotional

states (Cummings et al. 1980, Finney et al. 1980, Hatsukami and

Pickens 1982, Marlatt and Gordon 1980), and physical discomfort

(Finney et al. 1980, Khatami et al. 1979, Moos et al. 1979).

These reported sources of relapse suggest three reasonable goals

for aftercare in drug treatment (Hawkins and Catalano, in press).

1) Aftercare should increase family and other social

support for successful living in the community

without dependence on drugs and should seek to

eliminate patterns of interaction with family and

peers that contribute to readdiction. In short,

aftercare should seek to develop or enhance

informal social supports in the community.

2) Aftercare should seek to increase involvement in

productive roles in the community, whether in work,

school, or the home.

3) Aftercare should facilitate former drug abusers'

involvement in active recreational and leisure

activities that do not involve the use of drugs.

158
We recently completed a study of reentry experiences of clients

leaving four drug-free residential treatment programs in two

Western cities to see the degree to which these goals are achieved

in existing residential treatment programs and to identify other

appropriate goals for aftercare from an empirical base. We examined the daily experiences of 54 subjects in the four residential

programs who were in the "reentry phase" of treatment, and we

studied the drug use of 43 clients of these programs during the

first 3 months after they left treatment. Social networks were

studied for a subsample of 38 of the 43 former clients for whom

complete social network data were available. The details of these

studies are provided elsewhere (Catalano and Hawkins 1984, Hawkins

et al. 1981, Hawkins and Fraser, in press), and the results are

summarized here.

REENTRY STUDY

We found that residential treatment clients in reentry participated in a number of conventional activities that are likely to be

important to rehabilitation. These included work and education,

active leisure, and social interactions with others who do not use

drugs. Substantial minorities of clients also reestablished linkages with their families, though these involvements were less

widespread. However, we also found that a substantial minority of

clients, ranging from 26 to 32 percent, evidenced deficits in

social skills at work, during active leisure, during social interactions with others who do not use drugs, and during family

interactions. (Deficits in social skills were coded when clients

did not interact appropriately in social situations given their

goals.) In addition, 38 percent of the working clients evidenced

deficits in task skills at work, and 30 percent evidenced deficits

in carrying out daily living tasks. (Deficits in task skills were

coded when clients did not adequately meet requirements in preparation for, or performance of, a specific activity.) Finally, 33

percent of the working clients evidenced deficits in coping skills

at work, 22 percent evidenced deficits in coping skills in interactions with family members, and 31 percent evidenced deficits in

coping skills in using human services. (Deficits in coping skills

were coded when clients failed to handle a reported difficulty in

a particular situation in a way that achieved a satisfactory

resolution.) Thus, although clients participated in these areas,

substantial minorities did not perform effectively in these

situations. Since an unskillful performance is not likely to be

rewarded, continued participation in these areas may be discouraged by poor performance.

Another finding from the reentry study was that a substantial

minority (24 percent) of subjects were exposed to drug users and

people engaged in other illegal activities during the reentry

phase. Following treatment, former clients inevitably encounter

drug users in their daily rounds of activities. The presence of

such interactions during reentry can be viewed as an opportunity

for clients to practice and develop skills for managing

159
potentially troublesome situations. However, nearly one-third of

those who had such interactions did not handle the situations

effectively.

Finally, with the exception of clients in one program who were

involved in Narcotics Anonymous self-help groups, almost none of

the reentry clients were involved in organizations or groups

outside the treatment program that could provide alternative

sources of social support and reinforcement for new living

patterns following treatment.

POST-TREATMENT FOLLOWUP STUDIES

To examine the possible effects of social influences on rehabilitation following treatment, followup data were collected on the

social networks of clients from these same residential programs at

1 month and 3 months after treatment. Complete data were available from 38 subjects. Personal networks of individuals with whom

the respondent had contact in the 30 days prior to the interview

were studied, using network mapping and q-sorting procedures.

Subjects in this study were divided into two groups: those who

used opiates in the first 3 months following treatment and those

who did not. A comparison of the social networks of these two

groups before and after treatment suggested possible linkages

between social network characteristics and prevention of a return

to drug use following treatment. We found that both groups had

significantly different social networks at 1 month after treatment

when compared with their pretreatment networks. There were

significantly fewer people in their networks known over 1 year,

fewer people with positive attitudes towards drugs, and fewer

illicit drug users.

In comparing post-treatment opiate users and nonusers, we found

that the two groups had similar network characteristics before

treatment. However, in the first month following treatment, the

networks of the two groups had become significantly dissimilar in

several respects. Those who did not use opiates in the first 3

months after treatment reported significantly fewer frequent users

of illicit drugs (excluding marijuana) in their networks than did

those who used opiates (3.4 percent compared with 20.2 percent).

Similarly, nonusers had significantly more nonusers in their

networks (70.1 percent) than did those who used opiates (44.5

percent). Additionally, the proportion of network members who

influenced the subjects to use drugs differed significantly at

1-month followup (2.6 percent of the networks of nonusers versus

20.4 percent of the networks of users). At 3 months following

treatment, the networks of the opiate users continued to include a

greater proportion of members who influenced the respondents to

use drugs (16.2 percent) than did the networks of nonusers (3.0

percent). In sum, those who used opiates following treatment had

networks that provided significantly greater reinforcement for

drug use than did those who did not.

160
While the small sample and short followup period call for caution

in generalizing from these results, they suggest that a return to

opiate use following treatment is likely to be accompanied by

involvement in a social network that includes significant social

reinforcement for drug use. While former clients appear to

restructure their social networks after leaving treatment, those

who use opiates following treatment tend to establish social

networks that contain more drug users, fewer people involved in

conventional activity, and more people supportive of drug use.

We also examined the alcohol- and drug-using experiences of 43

clients leaving treatment during the study period who had been in

treatment at least 3 months. Half (51 percent) of this sample had

graduated from treatment and the other half (49 percent) had left

before completing treatment. A relapse to drugs or alcohol was a

relatively common experience in the first 3 months after treatment

exit for this sample (see table 1). Only 14 percent of the sample

reported remaining drug- and alcohol-free throughout the period.

About 12 percent reported having used only alcohol in this period.

Thus, close to 75 percent of the sample had used an illicit substance at least once in 3 months following treatment. Slightly

over half the sample reported using illicit drugs other than marijuana in this period.

TABLE 1. Most serious substance used in 3-month followup and mean

number of weeks of use

Most Serious

Substance Used

Percent Using

at Least Once

(N = 43)

Mean Number

of Weeks of Use

None 14.0 0

Alcohol 11.6 4.8

Marijuana 23.3 5.5

Nonopiates 14.0 1.7

Opiates 37.2 4.9

TOTAL 100.0*

*Numbers do not sum to 100 percent due to rounding.

A single drug use experience following treatment can be expected

as part of the recovery process and may not indicate a serious

relapse problem. To investigate the extent of relapse, the number

of weeks during the 11-week followup period in which subjects used

any of 12 substances was recorded. All subjects were classified

into one of four categories according to the most "serious" substance used (i.e., opiates, nonopiates, marijuana, alcohol). The

number of weeks of use of the most frequently used substance in

161
the most serious category was taken as an indicator of the extent

of the relapse. This is a conservative indicator of relapse

because it considers the frequency of only the most "serious" substance used. For instance, if a subject used marijuana several

times a day but used heroin once, the subject would be classified

as an opiate user for 1 week. The average number of weeks of use

for each category of substance is listed in table 1. For all

categories except nonopiates, the mean period of use in the 11

weeks was more than a month. For those whose most serious

category of use was nonopiates, the average period of use was

slightly less than 2 weeks.

These data have a limited capacity to indicate the extent of

relapse because of the short followup period. However, they do

indicate that relapse to substance use is a common experience.

Over 85 percent used some substance, and almost three-quarters of

the subjects used illicit substances. Moreover, the majority of

those who relapsed did so more than once. Slightly over 60 percent of those who relapsed during the 11-week period did so in

more than 1 week of the period.

These studies of reentry and post-treatment experiences of residential drug treatment clients suggest that a skills training

mission should be added to those mentioned earlier as a fourth

goal for aftercare.

4) Aftercare should assist former drug abusers to

develop and practice the skills necessary to maintain sobriety after leaving treatment. These

include: a) skills to become involved in social,

productive, and leisure activities in the larger

community, b) skills to cope with stress and

"negative emotional states" without resorting to

drug use as a form of self-medication, c) skills to

recognize and avoid situations with a high risk for

relapse, and d) skills to cope with a slip into

drug use without allowing it to become a full-blown

relapse.

AN EXPERIMENTAL INTERVENTION TO PREVENT RELAPSE

Based on the data reviewed above, we designed an experimental

program that seeks to address the four goals of aftercare we have

identified. We based the experimental program on a theory of

rehahilitation (Hawkins and Catalano 1980) that integrates the

existing data on relapse into a causal model that includes

specific points of intervention for aftercare and expected consequences of each intervention component. The theory of rehabilitation specifies the competing pressures to return to drug use and

to remain drug free. Following control theory (Hirschi 1969), the

theoretical model hypothesizes that a social bond consisting of

attachment to conventional others, commitment to conventional

lines of action, and belief in the conventional moral order will

162
inhibit a return to regular use of illicit drugs. Further, it is

hypothesized that this social bond results from a social process

involving: 1) involvement in conventional activities and interactions with conventional others, 2) the skills to participate

effectively in these involvements and interactions, and 3) the

rewards forthcoming from skillful performance in conventional

activities and interactions.

As shown in figure 1, four related paths are hypothesized to

explain continued drug use following treatment. Conventional

interaction and involvement paths are directly relevant to the

establishment of a bond to the social order. Both paths start

with willingness to participate in conventional life. In addition

to this willingness, opportunities for conventional interactions

and involvements are required. These opportunities and willingness lead to actual involvements. The skills applied in these

involvements and the rewards available from the environment determine the rewards experienced bv particioants. Where conventional

involvements or interactions are perceived as rewarding, they

should lead to the development of a social bond that inhibits a

return to drug abuse.

The two remaining paths in the model are directly relevant to a

return to drug abuse. The first is an "interaction with drug

users" path, and the second is a "criminal involvement" path.

Identical processes are hypothesized to operate on these paths.

Willingness to become involved in conventional life inhibits

interaction with drug users or involvement in criminal activities.

while opportunities to become involved or to interact in these .

forms of deviant behavior enhance the orobability of actual

deviant involvement. If socialization'has been effective and a

bond to the conventional order has developed, elements of the bond

of attachment, commitment, and belief will inhibit illicit

involvement. In the absence of a strong conventional social bond,

when illicit involvements or interactions are perceived as

rewarding, they will lead to continued criminal involvement, to

continued interactions with users, and, ultimately, to drug abuse.

The intervention points of the model are underlined in figure 1.

Interventions that increase opportunities for conventional

involvement and interaction are expected to strengthen the social

bond and thus to prevent a return to drug use. In addition,

specific skills are identified in the model. These skills are

expected to affect the likelihood that rewards will be experienced

for specific involvements. Effective consequential thinking about

one's use of drugs or alcohol is expected to increase one's

willingness to become involved in conventional life as well as the

rewards from participating in conventional life. Consequential

thinking skills enhance one's ability to perceive the connection-,

between drug and alcohol use and problems, thus tying perceived

costs to drug use. Conventional social, problem-solving, and

stress-coping skills increase the likelihood that rewards will be

obtained from involvement with conventional others. It is

163
FIGURE 1. Theoretical model of rehabilitation
hypothesized that the more skillful one's performance, the greater

the probability that this performance will be rewarded. Skills to

avoid participation in illegal activities (e.g., "saying no" to

drugs, avoiding drug users, avoiding places of drug use, and

resisting intrapersonal temptation to use drugs) are hypothesized

to decrease initial reinvolvement in drug use. Finally, the

greater one's ability to cope effectively with a possible relapse

to drug use, the less the probability that one's initial use of

drugs will be experienced as uncontrollable and will lead to

continued drug use.

Our experimental aftercare intervention seeks to address both the

client skills and the environmental conditions related to drug

relapse. It seeks to increase opportunities, skills, and rewards

for successful participation in the conventional world. In addition, it seeks to increase skills to avoid interaction with drug

users, to avoid involvement in illegal activity, and to prevent

and cope with relapse. The opportunity and reward components

involve environmental change. We seek to assist clients to attain

the rewards associated with socially accepted activities and

interactions by providing opportunities for involvement in these

activities and interactions, hy systematically helping them to

develop better problem-solving, social, and coping skills, and by

helping to ensure that their posttreatment networks contain strong

social supports for prosocial rather than drug-using behaviors.

The experimental aftercare program, called Project Skills, works

with clients who are beginning the reentry stage (live in/work

out) of treatment in residential programs. These subjects have

been exposed to the residential treatment regimen for at least 3

months, and still have the support offered by the drug-free

environment for at least the first 10 weeks of the supplemental

experimental intervention.

Project Skills combines behavior-skills training with involvement

in activities and social network development (see table 2).

Behavioral-skills training recognizes social and interpersonal

factors that influence people to return to drug use (Perry and

Murray 1982). Our use of this approach is based on evidence that

individuals can be taught behaviors that lead to environmental

self-control and socially acceptable and adaptive forms of

reinforcement and reward (Bandura 1973, 1977; Chaney et al. 1978;

Pentz and Kazdin 1982). We seek to inoculate individuals against

a return to drug use by showing them how to avoid drug users and

drug situations, how to solve problems, how to interact with

nonusers in ways that are reinforcing, and how to cope with highstress and high-risk situations, which might lead to a relapse

into drug use (Kellam et al. 1982, Meichenbaum and Novaco 1978).

165
TABLE 2. Project Skills structure

Opportunities Skills Rewards

Pairing with a Social Volunteer as support-

"straight" commu- ive practice person

nity volunteer Problem-solving

Phase III support and

Involvement in an Stress-coping maintenance group

informal community group or Social network Interest identification

organization assessment

Avoidance and refusal

Relapse prevention

Relapse-coping

Skills training is only one part of the intervention. A common

problem with skills training approaches has been generalization

(Goldstein and Kanfer 1979, McFall 1982). In his reconceptualization of skills training, McFall (1982) emphasizes that training

people to perform better is only one aspect that should be

addressed. Additionally, environmental stimuli should be altered

to reduce problem behaviors.

The activities involvement and network development components of

Project Skills pair a client with a partner from the community who

does not use drugs. The pair selects and participates in a community organization that interests the client. The organization,

focused on social, leisure, service, or religious activities,

serves as a resource for meeting new people supportive of rehabilitation. The community partner provides support for getting

involved in the organization, practices new skills with the

client, and supports the client through any problems encountered

in becoming involved in an organization. We hypothesize that

organizational linkages will help to structure former abusers'

involvements in the "straight" world, provide a source of continuing social support, and provide a source of reinforcement in an

interest area other than work,

THE INTERVENTION

Project Skills is divided into three phases having distinctive

goals and activities. All three phases are planned to assist

clients to improve their skills, to increase their involvement in

community activities, and to develop supportive social networks.

166
Phase I

Phase I lasts 3 weeks. During Phase I, clients meet twice a week

for 2 hours per session to learn basic interpersonal, problemsolving, stress-coping, and refusal skills. These skills are:

social introductions and assertive behavior, giving and receiving

praise and criticism, structured problem-solving, stress management, social network assessment, and saying "no" to drugs and

alcohol.

Each lesson in skills improvement is derived from a problem situation in a behavioral role-play test developed by the authors.

This role-play test was developed by abstracting situations from

weekly interviews with clients that led to relapse, in either the

client's judgment or in a clinician's judgment. Eighty of these

situations were pretested in a role-play format; forty-three were

retained in the final instrument. Experimental clients are taught

the components of an effective response to the problem situations

from the role-play test. Half of the situations are not

rehearsed, so that the degree of the clients' generalization to

unrehearsed situations can be examined. The techniques used to

teach effective responses are instruction, modeling, role-playing,

structured feedback, videotaped feedback, and group discussion.

Volunteer training. Prior to the start of Phase I, volunteers

recruited from the community attend an orientation session at

which they receive information about Project Skills and learn

about the role of the community partner. They are interviewed

individually, and those selected to be community partners are

asked to make a commitment to be a partner for 9 months.

In our program, this recruitment produced 108 applicants, of whom

57 were selected. The greatest number of volunteers selected to

participate after orientation and screening were the result of

personal contacts of staff members and from "want ads." In terms

of staff time necessary to recruit volunteers, "want ads" were

clearly the most efficient producers of volunteers. The screening

process was similar to a job application, In the personal interview, the volunteers' motives for applying, their personal drug

and alcohol history, the level of commitment required by the job,

and their responses to troublesome situations that could occur as

a result of their participation were discussed.

The volunteer partners meet once a week for 2 hours during Phase

I . They learn about residential drug treatment, how to work with

clients in the partnership role, community organizations that may

be of interest to their client partners, how to help clients find

and join organizations in order to meet positive people, and

social skills that will help them get to know their client

partners.

During these first 3 weeks of intervention, the main goal is to

teach clients and community partners the basic skills necessary

167
for involvement with Project Skills. The two groups are gradually

integrated through informal refreshment breaks during the

sessions. At the third session, clients and community partners

are paired, based on staff observations of skills, interests, and

interactions during the sessions and refreshment breaks.

Phase II

During the 7 weeks of Phase II, clients and their community partners find and join a community organization of interest to the

client. Once a week, clients and their volunteer partners meet in

a training session to plan and evaluate their community networking

activities. These activities include calling potential organizations, visiting these organizations together, joining or volunteering at one organization of interest to the client, meeting

nonusers in that organization, and developing a plan to join

another organization if interest in the original organization

fades. Project Skills' criteria for acceptable organizations are

designed to maximize the organization's reinforcement potential

for the client and to maximize opportunities to meet prosocial

individuals who do not use drugs. These criteria are:

1) The group should meet regularly (not less than once

per month).

2) The group must provide the opportunity to interact

with the same people over time.

3) Participation should be as a member of a larger

group, rather than alone (e.g., playing a team

sport rather than solo weight lifting for personal

improvement).

4) The organization's activity should be one the

client is willing to pursue even if the volunteer

is unable to participate with the client.

5) The organization and client should have a shared

purpose, interest, or function.

During Phase II, experimental clients also continue to meet

separately once each week to work on drug avoidance, problemsolving, social, and coping skills. The skills taught are:

dealing with being treated unfairly, dealing with depression,

coping with a slip into drug use, dealing with success, and

dealing with personal high-risk relapse situations.

To minimize possible conflicts with collaborating residential

programs, community volunteers visit their partner's treatment

program and meet the client's counselor and other staff during

this phase. These visits help community volunteers to understand

their clients better and help residential program staff to

understand the supplemental experimental intervention.

168
At the end of Phase II, a combined promotion and graduation

ceremony is conducted for those who have met project criteria.

Clients and volunteers who have completed all assignments of

Phases I and II are promoted to Phase III.

Phase III

Phase III, which lasts 6 months, seeks to: 1) increase generalization of skills, 2) provide support for clients, who typically

leave their residential programs during this time, 3) allow

clients to become more fully involved in a community organization

while still having the support of a volunteer and Project Skills

staff, 4) provide an opportunity to switch community organizations

if the first one chosen does not meet the client's expectations,

and 5) provide time for actual community reentry problems to occur

and be solved with the support of the volunteer, Phase III support

group, and staff.

During Phase III, volunteer and client pairs are expected to

continue participation in at least one community organization, to

meet together for at least 8 hours per month, to continue to use

the problem-solving methods learned in Phases I and II to deal

with emerging problems, and to maintain contact with others in

their training group through a biweekly problem-solving and

support group meeting.

Each Phase III meeting begins with an informal potluck dinner and

social time, followed by an hour and a half of structured activity, which includes positive reports of personal events and an

activity designed to enhance a skill learned in Project Skills.

Either in the middle or at the end of the structured time, stress

reduction exercises are practiced.

All client-volunteer pairs are supervised, using a case management

system. Each case manager is responsible for contacting one of

the pair each week, alternating between the client and the volunteer. Each month, the case manager writes a report on clientvolunteer activities for each pair. Those who complete Phase III

requirements yraduate from Project Skills and are no longer active

clients. The clinical staff awards certificates of completion to

this graduating group.

RESEARCH METHODS

Five residential drug treatment centers (therapeutic communities,

or TC's) originally agreed to collaborate in an experimental

research project with Project Skills and to provide access to

clients approaching the reentry stage (live in/work out) of

treatment. Early in the project, one of the programs lost its

funding and closed. The other four programs remained open during

the entire project period, although two of the programs merged

during the project. The programs ranged in style from traditional

TC confrontation milieu therapy utilizing paraprofessional staff

169
exclusively to a program staffed by both paraprofessionals and

professionals that makes extensive use of community programs and

personnel for therapeutic referrals. Length of treatment required

for TC graduation ranges from 6 to 24 months. However, the retention rates in these TC's are similar at 1, 6, and 12 months (see

table 3). Approximately 40 percent of clients completing intake

remain in treatment after the first month, 14 percent remain at 6

months, and 10 percent or fewer remain in treatment for 1 year.

TABLE 3. Percentage of clients remaining in treatment, by month

by program, November 1979 - November 1981

Percent in Treatment at End of Month

Program 1 6 12

1 (N=123) 39 15 10

2 (N=223) 8 1

3 (N=82)

35

44 18 8

4 (N=353) 42 14 5

Clients who were within 6 weeks of beginning the reentry phase of

their TC programs or who had been in the reentry phase 6 weeks or

fewer at the starting date of each round of Project Skills training were eligible for inclusion in the supplementary aftercare

intervention. Eligible subjects were randomly assigned to the

control and experimental conditions by a randomized block design

stratified by program and by sex after the subjects had consented

to participate in the project and completed assessment interviews.

Seven sample pools were constructed in this way.

In spite of written sample pool guidelines, which were explained

verbally prior to construction of each TC's sample pool, several

subjects who were not eligible were referred by their TC's to

Project Skills. Table 4 presents the sampling and assignment

results of the first five groups of Project Skills, including the

number of subjects initially referred by their TC's who refused to

participate or were ineligible for inclusion in the sample pool.

During groups two and five, a disproportionate random sample at

one program was used to increase the number of treated experimentals. This procedure produced 10 more experimental than

control subjects.

170
TABLE 4. Results of subject recruitment groups 1-5

Number of Total

Subjects Refused Experimentals Controls

Referred

Ineligibie

N (Percent)

Participants

N (Percent) N N N (Percent)

134 24 (17.9) 16 (11.9) 5 2 4 2 94 (70)

ASSESSMENT PROCEDURES

Historical and baseline data were collected on all clients willing

and eligible to participate in Project Skills prior to their random assignment to experimental or control conditions. The Client

History is a structured interview that collects information on the

client's life before TC entry, including drug use, crime, social

network, demographics, and employment history, as well as current

social network information, and current attitudes toward a variety

of issues. The Problem Situation Inventory (PSI) is a taperecorded role-play test in which subjects respond to potentia'l

problem situations. This instrument was developed to assess skill

levels of clients in six areas: problem-solving and decisionmaking skills, social skills, stress-coping skills, refusal

skills, relapse prevention skills, and relapse-coping skills. The

PSI was completed again for experimental and control subjects

immediately after the first 10 weeks of training (Phase I and II),

and a shortened version was administered at 6 and 12 months after

completion of Phase II to examine treatment maintenance issues.

The PSI rating system is highly reliable. Intrarater reliability

rates were 91.6 percent for the component skills and 91.7 percent

for the overall score on the PSI. Interrater reliability was 88.5

for the component skills and 91.1 for the overall score. Rating

has just been completed for pre- and post-tests, and these data

are not yet analyzed.

Followup interviews were attempted with all subjects at 6 and 12

months after completion of Phase II. These interviews collect

data on the subject's activities, including drug use, employment,

leisure activities, organizational involvement, criminal activities, additional treatment, incarceration, social networks,

problem areas, and helpful influences.

DATA ANALYSIS

Historical and 6-month followup data are presented for the first

five of seven groups of subjects. Table 5 presents demographic

and background data for the 94 subjects assigned to the experimental and control groups. As can be seen, the sample was predominantly male (80.4 percent) and white (75.9 percent), and the mean

age was 26.5. The sample averaged 11.5 years of education, and

37.9 percent had a job before entering residential treatment. On

the average, subjects had used three types of drugs regularly.

171
Seventy-two percent of the subjects had used opiates at some time,

and 50 percent had used opiates regularly. Slightly more than 86

percent of the sample had been involved in criminal activity prior

to entering treatment. These characteristics are similar to those

of other residential treatment program populations (DeLeon 1984,

Bale et al. 1980), although the Seattle sample has more whites and

fewer Hispanics.

TABLE 5. Experimental/control comparability at baseline

Experimental Control

(N=49) (N=38)

Age

Years of education

Percent male

Percent white

Percent with a job before entering

treatment

Number of different types of drugs

ever used regularly

Number of different types of drugs

used regularly in last month in

community before treatment

Number of different types of drugs

ever used

Percent ever used opiates

Percent ever involved in crime

26.6 26.4

11.3 11.8

77.5 84.2

69.4 84.2

36.7 39.5

3.3

2.0

4.5

71.4

89.8

3.3

1.9

4.5

73.7

81.6

The experimental and control groups exhibit no significant differences on these variables. The experimental group contains fewer

whites, and its members have a history of slightly more criminal

involvement. Overall, it appears that random assignment procedures produced comparable experimental and control groups.

Presented next are 6-month followup data for the first five

groups. The reader is cautioned that these data are preliminary

outcomes, since the entire sample consists of seven groups. The

effects of the experimental intervention may have improved over

time as clinical staff became more experienced; however, cohort

172
effects have not yet been examined. In addition, more definitive

followup information on the maintenance of the treatment gains is

being collected in the 12-month followup interview. It is expected that outcomes during this extended followup period will

more accurately reflect the power of the experimental

intervention.

Table 6 displays project participation and followup interview

completion data for the first five groups. Slightly more experimentals than controls have been located and interviewed. However,

the interview completion rates for both groups exceed 90 percent.

Those not located or refusing to be interviewed are likely to have

worse outcomes as demonstrated by Polich et al. (1980), but the

nearly equal percentages of interviews completed in the experimental and control groups lends confidence to the comparability of

the followup data for subjects in these two conditions.

TARLE 6. Project participation and followup interview completion,

groups 1-5

Experimental Control Total

Total Participants N=52 (Percent) N=42 (Percent) N=94 (Percent)

Percent interviewed 49 (94.2) 38 (90.5) 87 (92.5)

at 6 months

Percent completing 34 (65.4) 32 (76.2) 66 (70.2)

10-week training and

equivalent controls

Two issues need to be considered before the discussion of results.

The first is time at risk during the 6 months following the 10

weeks of Phase I and Phase II intervention. Project Skills

accepted subjects at the beginning of the reentry phase of residential treatment. Thus, a proportion of the sample stayed in

residential treatment during part or all of the 6-month followup

period. Approximately a third of the sample were residents in a

TC for the entire 6-month followup period, though all these subjects worked, went to school, or looked for work outside their TC

during this period. Thus, even these subjects had opportunities

to use drugs during this period. As noted earlier, our previous

reentry study found that a quarter of the reentry sample were

exposed to drugs and drug abusers during the reentry phase of

treatment.

173
To see whether the reentry phase of TC treatment should be considered an at-risk period for drug use, we also investigated

subjects' reported drug use while in the reentry phase. Examining

the month of most frequent drug use for each client during the

6-month followup period, we found that 24 percent of the months of

heaviest use of illicit drugs other than marijuana were months

when clients were in the reentry phase of treatment. Thirty-one

percent of the months of heaviest use of marijuana were months

when clients were in treatment. These data indicate that the TC

reentry phase clearly is a period of risk for drug use. Thus we

have considered the entire 6-month period following Phase II as

the at-risk period regardless of whether subjects were living in a

TC or not.

The second issue concerns the designation of experimental and

control group subjects for analyses. We examined outcomes in two

ways. We compared all subjects assigned to the experimental condition with all subjects assigned to the control group, regardless

of actual exposure to the Project Skills intervention. Second, we

compared "treated experimentals" with an equivalent control subsample who remained in residential treatment for the same period

of time. Of the 52 experimentals in the first five groups,

slightly over 65 percent completed the 10-week experimental Phase

II training program. Slightly over 76 percent of the control

group remained in residential treatment for this same 10-week

period. We designate these subjects as "treated experimentals"

and equivalent controls. This latter analysis allows assessment

of the possible effects contributed by Project Skills over and

above TC residence. When evaluating the incremental gains of a

brief intervention in addition to a long-term intervention, it is

essential that subjects have an adequate opportunity to be exposed

to the brief intervention. The comparison of the treated experimental group to those members of the control group who remained in

residential treatment during the same time period helps to ensure

comparability across groups on motivation factors that may be

related to outcomes.

The outcomes suggested for assessment by our theoretical model are

opportunities for conventional involvements and interactions,

skills, perceived rewards for conventional participation, bonding

to conventional people and activities, and crime and drug use.

The data on skill levels have not yet been analyzed, hut preliminary results on other outcomes for groups 1-5 are available.

When the entire experimental and control groups are compared, no

significant outcome differences appear in the first five waves of

6-month followup data. The one comparison approaching significance is the percentage participating in organizations. When

outcomes of treated experimentals and their equivalent controls

are examined for the first five groups, the differences are also

not significant. However, some of the differences suggest favorable trends that may prove to be significant when the full sample

of seven groups is examined.

174
Though not statistically significant, the preliminary findings are

displayed in table 7. A greater proportion of the treated experimental group (45.5 percent) participated in prosocial organizations during the last month of the followup period than of the

equivalent control group (30 percent). It appears that the intervention produced greater opportunities for conventional involvement outside of work and school settings. In the area of social

networks, 60 percent of treated experimentals' networks were

reported as influencing subjects not to use drugs as compared with

50 percent of the equivalent control sample's networks.

Virtually the same proportions of the two groups' networks were

reported to he nonusers of drugs (46 percent). On the average, 35

percent of experimentals' networks did not use drugs and influenced experimental subjects not to use drugs, compared with 30.9

percent of the equivalent control group's networks. Finally, a

slightly greater proportion of the treated experimentals have

reported incorporating persons in their networks that they met at

organizations or at Project Skills. Thus, the treated experimentals appear to be incorporating slightly more prosocial influences and more people influencing them not to use drugs into their

networks than the control group is.

In the area of commitment to productive activities, it appears

that the treated experimental group is slightly more committed to

work and school than their equivalent controls are. If these

prosocial influences are maintained and developed, it is hypothesized that they will lead to increased opportunities for bonding

to prosocial others and to less drug use at l2-month followup.

Turning to drug use, two types of measures are shown in table 7.

The percentage of the sample abstaining from drug use during the

entire 6-month followup period favors the control group. Of the

experimental group, 45.5 percent reported not using any drugs or

alcohol, and 56.7 percent of the control group reported abstaining

during this period. However, when the number of drug-free and

drug- and alcohol-free weeks in the 6-month followup period are

examined, the outcome is more favorable for the treated experimental group. The average number of drug-free weeks during the

24-week period is 20.5 for the treated experimental group and 18.7

for the equivalent control group. When the average number of

weeks free from both drugs and alcohol is examined, the treated

experimentals enjoyed 19.2 weeks free of use of all substances,

while the equivalent control group had an average of only 14.9

weeks drug- and alcohol-free. These data suggest the possibility

that the experimental skills training may be producing a greater

ability to curtail a slip and prevent it from becoming a fullblown relapse, since there are fewer abstainers but more abstinent

weeks in the treated experimental group. The final outcome

presented is the amount of criminal involvement. The selfreported rates of official contact are low in both groups.

175
TABLE 7. Selected comparisons of treated experimentals and

equivalent controls at b-month followup, groups 1-5

Experimental Control

(N=33) (N=30)

1. Organizational participation

Percent participating in organizations during most recent month

2. Networks

a. Percent who influence not to use

b. Percent not drug users

c. Percent hard-drug users

d. Percent met in organization or

Project Skills

e. Percent who use no drugs and influence subject not to use

3 . Commitment (range 1-5)

a. Commitment to work

b. Commitment to school

4. Drug use

a. Percent abstinent (drugs only)

b. Percent abstinent (drugs and

alcohol)

c. Drug-free weeks, excluding alcohol

d. Drug-free weeks, including alcohol

5. Crime

a. Mean number of times arrested

b. Mean number of convictions

c. Mean number of times incarcerated

45.5 30.0

60.0 50.8

46.7 46.1

10.2 6.6

12.1 8.2

35.0 30.9

3.1 2.7

4.1 3.8

57.6 66.7

45.5 56.7

20.5 18.7

19.2 14.9

.12 .20

.06 .17

.09 .23

DISCUSSION

While these data are preliminary, it appears that some variables

are trending in the hypothesized direction, while others are not.

The pattern of variables trending in the hypothesized direction is

not consistent. For instance, differences in the hypothesized

direction have been produced in opportunity for involvement, drugfree weeks, and commitment, yet not on the intervening reward

variables. Nor do the opportunities provided through Project

Skills appear to be having as large an impact on social networks

as we expected. Because of this, we are reexamining our approach

to social network intervention. Our current thinking is not to

rely exclusively on volunteers to help with network development.

Although it appears that volunteers became a part of experimental

subjects' social networks and provided emotional sustenance, it

176
does not appear that they were able to serve as effective facilitators for subjects' network development. It may be beneficial to

have more highly skilled people systematically assist subjects to

reconstruct their networks. This task includes giving emotional

sustenance, but also requires giving critical feedback on performance, encouraging selection and participation in organizations,

and encouraging subjects to meet people at organizations rather

than huddling together as a two-person protection unit.

Another surprising finding is that experimental subjects are not

reporting greater rewards from conventional activities. While

Project Skills subjects are participating in organizations, this

participation does not seem to be as rewarding or to be maintained

as well as we had hoped. One reason for this may be a weakness in

our procedures for helping subjects define interests for selecting

an organization. It could be that subjects chose organizational

activities more out of need to comply with Project Skills'

requirements than to discover real interest areas. A more intensive case management system to explore interests in depth and

ensure a greater exposure to different organizational settings may

increase the rewards subjects perceive for this involvement.

Alternatively, it may be that experimental subjects have been

pushed out of their comfort zone and into a new and anxiety-filled

area of involvement by their organizational involvement. In this

case, skills training should eventually contribute to increases in

perceived rewards once subjects reduce their anxiety over the newness of the organizational participation. If this were the case,

we would expect a trend toward more perceived rewards for conventional activities among experimental subjects in the 12-month

followup data.

The 6-month data presented above suggest some trends, but have

produced no significant differences with the portion of the sample

analyzed so far. In conclusion, we would like to leave the reader

with two thoughts. The theoretically based approach to aftercare

experimentation that we are using outlines hypothesized processes

of rehabilitation. As a blueprint for experimentation, it allows

us to examine specific points where experimental interventions

appear to be affecting intervening variables and where they are

not. In this way, we are able to examine and adjust implementation prior to theory testing. This type of model-based intervention will allow us to ascertain success of particular components

of the intervention and to see which components are not working

and should be improved. We feel that this is an appropriate

approach for research and development in intervention programming.

Using this approach avoids throwing out the baby with the bathwater by allowing researchers to fine-tune or overhaul specific

components of the intervention before abandoning an empirically

based theory. Without a theoretical base with specified intervention points, it is more difficult to decide whether to change

components of one's intervention or to abandon the intervention

approach and theory completely.

177
In closing, the second point is that the 6-month followup period

is usually a shakeout period during which clients of residential

treatment centers experiment with life beyond treatment. Experimenting with a new style of life, testing resolve not to use

drugs, and attempting to return to community living make this a

relatively unstable transition period. Thus, we are interested in

looking at the 12-month followup data, which should reflect more

stable patterns of involvement, bonding, and drug use. Presently,

we have 12-month followup data on only the first two Project

Skills groups. We present the data on drug-free weeks for these

groups in table 8. These data show increased drug use during this

second 6-month period for both groups. However, when the mean

number of drug-free weeks for the treated experimentals and equivalent controls are compared, the treated experimentals show an

average of nearly 8 more drug-free weeks than the equivalent

controls.

TABLE 8. Twelve-month followup results, groups 1 and 2

Treated Equivalent Total Total

Experimentals* Controls** Experimentals* Controls**

(N=14) (N=12) (N=22) (=16)

Average 14.9 1.3 12.2 7.0

number of

drug-free

weeks***

*One subject has not been interviewed in this condition.

**Two subjects have not been interviewed in this condition.

***24 weeks possible in period.

When all experimental and control subjects assigned to groups 1

and 2 are compared, this difference remains in the experimental

group's favor, with a mean difference of approximately 5 drug-free

weeks. If this trend continues, it would suggest a maintenance

effect of Project Skills. We are eager to continue followup and

analysis of the 12-month data in the coming months.

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Goldstein, A.P., and Kanfer, K.H., eds. Maximizin treatment

gains: Transfer enhancement in psychotherapy. New York:

Academic- Press, 1979.

Harbin, H.T., and Mazier, H.M. The families of drug abusers: A

literature review. Fam Process 14:411-431, 1975.

Hatsukami, D., and Pickens, R.W. Post-treatment depression in an

alcohol and drug abuse population. Am J Psychiatry

139(12):1563-1566, 1982.

Hawkins, J.D. Reintegrating street drug abusers: Community roles

in continuing care. In: Brown, B.S., ed. Addicts and

Aftercare: Community Integration of the Former Drug User.

Beverly Hills, Calif.: Sage Publications, 1979. pp. 25-79.

Hawkins, J.D., and Catalano, R.F. "Reversing Drug Abuse: A

Theory of Rehabilitation." Paper presented at the annual

meeting of the Pacific Sociological Association, 1980.

Hawkins, J.D., and Catalano, R.F. Aftercare in drug abuse

treatment. Int J Addict, in press.

Hawkins, J.D., and Fraser, M.W. The social networks of drug

abusers before and after treatment. In: Einstein, S., ed.

Drug and Alcohol Use: Issues and Factors. New York: Plenum,

in press.

Hawkins, J.D.; Olson, D.; and Catalano, R.F. Therapeutic community reentry: The transition from residential treatment to

community living. NIDA Grant Final Report, School of Social

Work, University of Washington, 1981.

Hejinian, C.L., and Pittel, S.M. "Can Marriage Survive Addiction

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In: Coates, T.J.; Petersen, A.C.; and Perry, C., eds.

Promoting Adolescent Health. New York: Academic Press, 1982.

Khatami, M.;. Woody, G.; and O'Brien, C. Chronic pain and narcotic

addiction: A multitherapeutic approach--a pilot study. Compr

Psychiatry 20(1):55-60, 1979.

Krohn, D.L.; Lanza-Kaduce, L.; Radosenich, M.; and Akers, R.L.

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alcoholism. Social Work 24(2):144-149, 1979.

Waldorf, D., and Biernacki, P.F. The natural recovery from opiate

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AUTHORS

Richard F. Catalano, Ph.D.

J. David Hawkins, Ph.D.

Center for Social

Welfare Research

School of Social Work

University of Washington

Seattle, WA 98195

181
monograph series

While limited supplies last, single copies of the monographs may be

obtained free of charge from the National Clearinghouse for Drug

Abuse Information (NCDAI). Please contact NCDAI also for

information about availability of coming issues and other

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1 FINDINGS OF DRUG ABUSE RESEARCH. Not available from NCDAI.

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2 OPERATIONAL DEFINITIONS IN SOCIO-BEHAVIORAL DRUG USE RESEARCH

1975. Jack Elinson. Ph.D., and David Nurco, Ph.D., eds. Not

available from NCDAI.

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3 AMINERGIC HYPOTHESES OF BEHAVIOR: REALITY OR CLICHE' Bruce J.

Bernard, Ph.D., ed. Not available from NCDAI.

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182
4 NARCOTIC ANTAGONISTS: THE SEARCH FOR LONG-ACTING PREPARATIONS.

Robert Willette, Ph.D.. ed.

GPO out of stock NTIS PB #247 096/AS $8.50

5 YOUNG MEN AND DRUGS: A NATIONWIDE SURVEY. John A. O'Donnell,

Ph.D. , et al. Not available from NCDAI.

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6 EFFECTS OF LABELING THE "DRUG ABUSER": AN INQUIRY. Jay R.

Williams. Ph.D. Not available from NCDAI.

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7 CANNABINOID ASSAYS IN HUMANS. Robert Willette, Ph.D., ed.

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8 Rx: 3x/WEEK LAAM - ALTERNATIVE TO METHADONE. Jack Blaine, M.D..

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Not available from GPO NTIS PB #253 763/AS $14.50

9 NARCOTIC ANTAGONISTS: NALTREXONE PROGRESS REPORT. Demetrios

Julius, M.D., and Pierre Renault, M.D., eds. Not available from

NCDAI.

GPO Stock #017-024-00521-5 $7.00 NTIS PB #255 833/AS $17.50

10 EPIDEMIOLOGY OF DRUG ABUSE: CURRENT ISSUES. Louise G. Richards,

Ph.D., and Louise B. Blevens, eds. Not available from NCDAI.

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11 DRUGS AND DRIVING. Robert Willette. Ph.D., ed. Not available

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12 PSYCHODYNAMICS OF DRUG DEPENDENCE. Jack D. Blaine, M.D., and

Demetrios 4. Julius, M.D., eds. Not available from NCDAI.

GPO Stock #017-024-00642-4 $5.50 NTIS PB #276 084/AS $17.50

13 COCAINE: 1977. Robert C. Petersen, Ph.D.. and Richard C.

Stillman, M.D.. eds. Not available from NCDAI.

GPO Stock #017-024-00592-4 $6.00 NTIS PB #269 175/AS $19

14 MARIHUANA RESEARCH FINDINGS: 1976. Robert C. Petersen, Ph.D.,

ed. Not available from NCDAI.

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15 REVIEW OF INHALANTS: EUPHORIA TO DYSFUNCTION. Charles Wm.

Sharp, Ph.D., and Mary Lee Brehm, Ph.D.. eds.

GPO Stock #017-024-00650-5 $7.50 NTIS PB #275 798/AS $28

16 THE EPIDEMIOLOGY OF HEROIN AND OTHER NARCOTICS. Joan Dunne

Rittenhouse, Ph.D., ed. Not available from NCDAI.

GPO Stock #017-024-00690-4 $6.50 NTIS PB #276 357/AS $20.50

183
17 RESEARCH ON SMOKING BEHAVIOR. Murray E. Jarvik, M.D., Ph.D.,

et al., eds. Includes epidemiology, etiology, consequences of

use, and approaches to behavioral change. From a NIDA-supported

UCLA conference.

GPO Stock #017-024-00694-7 $7.50 NTIS PB #276 353/AS $29.50

18 BEHAVIORAL TOLERANCE: RESEARCH AND TREATMENT IMPLICATIONS.

Norman A. Krasnegor, Ph.D.. ed. Theoretical and empirical studies

of nonpharmacologic factors in development of drug tolerance.

GPO Stock #017-024-00699-8 $5.50 NTIS PB #276 337/AS 516

19 THE INTERNATIONAL CHALLENGE OF DRUG ABUSE. Robert C. Petersen.

Ph.D., ed. Papers from the VI World Congress of Psychiatry.

GPO Stock #017-024-00822-2 $7.50 NTIS PB #293 807/AS $28

20 SELF-ADMINISTRATION OF ABUSED SUBSTANCES: METHODS FOR STUDY.

Norman A. Krasnegor, Ph.D., ed. Techniques used to study basic

processes underlying abuse of drugs, ethanol, food, and tobacco.

GPO Stock #017-024-00794-3 $6.50 NTIS PB #288 471/AS $22

21 PHENCYCLIDINE (PCP) ABUSE: AN APPRAISAL. Robert C. Petersen,

Ph.D., and Richard C. Stillman, M.D., eds. for clinicians and

researchers, assessing the problem of PCP abuse.

GPO Stock #017-024-00785-4 $7.00 NTIS PB #288 472/AS $25

22 QUASAR: QUANTITATIVE STRUCTURE ACTIVITY RELATIONSHIPS OF

ANALGESICS, NARCOTIC ANTAGONISTS, AND HALLUCINOGENS. Gene

Barnett, Ph.D.; Milan Trsic. Ph.D.; and Robert Willette. Ph.D.;

eds. Not available from NCDAI.

GPO Stock #017-024-00786-2 $8.00 NTIS PB #292 265/AS $35.50

23 CIGARETTE SMOKING AS A DEPENDENCE PROCESS. Norman A.

Krasnegor. Ph.D., ed. Discusses factors involved in the onset,

maintenance, and cessation of the cigarette smoking habit.

Includes an agenda for future research.

GPO Stock #017-024-00895-8 $6.00 NTIS PB #297 72l/AS $19

24 SYNTHETIC ESTIMATES FOR SMALL AREAS: STATISTICAL WORKSHOP

PAPERS AND DISCUSSION. Jos. Steinberg, ed. Papers from a workshop on statistical approaches that yield needed estimates of

data for States and local areas. Not available from NCDAI.

GPO Stock #017-024-00911-3 $8.00 NTIS PB #299 009/AS 523.50

25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE. Yorman

A. Krasnegor, Ph.D., ed. Papers on commonalities and

implications for treatment of dependency on drugs, ethanol, food,

and tobacco.

GPO Stock #017-024-00939-3 $5.00 NTIS PB #80-112428 $22

26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasneqor, Ph.D.,

ed. Reprint of the behavioral section of the 1979 Report of the

Surgeon General on Smoking and Health; introduction by editor.

GPO out of stock NTIS PB #80-118755 $17.50

184
27 PROBLEMS OF DRUG DEPENDENCE, 1979: PROCEEDINGS OF THE 41ST

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG DEPENDENCE, INC. L.S. Harris, Ph.D., ed. Not available from NCDAI.

GPO Stock #017-024-00981-4 $9.00 NTIS PB #80-175482 $37

28 NARCOTIC ANTAGONISTS: NALTREXONE PHARMACOCHEMISTRY AND

SUSTAINED-RELEASE PREPARATIONS. Robert Willette, Ph.D., and

Gene Barnett, Ph.D.. eds. Papers report research on sustainedrelease and long-acting devices for use with the narcotic antagonist naltrexone. Not available from NCDAI.

GPO Stock #017-024-01081-2 $7.00 NTIS PB #81-238875 $23.50

29 DRUG ABUSE DEATHS IN NINE CITIES: A SURVEY REPORT. Louis A.

Gottschalk, M.D., et al. Not available from NCDAI.

GPO Stock #Ol7-024-00982-2 $6.50 NTIS PB #80-178882 $17.50

30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY PERSPECTIVES.

Dan J. Lettieri, Ph.D.; Mollie Sayers; and Helen Wallenstein

Pearson, eds. Volume presents summaries of major contemporary

theories of drug abuse by each of 43 leading theorists.

GPO Stock #017-024-00997-1 $10.00 Not available from NTIS

31 MARIJUANA RESEARCH FINDINGS: 1980. Robert C. Petersen, Ph.D.,

ed. The text of the 8th Marijuana and Health report to Congress

and the background scientific papers on which it was based.

GPO out of stock NTIS PB #80-215171 $20.50

32 GC/MS ASSAYS FOR ABUSED DRUGS IN BODY FLUIDS. Rodger L. Foltz,

Ph.D.; Allison F. Fentiman, Jr., Ph.D.; and Ruth B. Foltz. A

collection of methods for quantitative analysis of several

important drugs of abuse by gas chromatography- mass spectrometry.

GPO Stock #017-024-01015-4 $6.00 NTIS PB #81-133746 $19

33 BENZODIAZEPINES: A REVIEW OF RESEARCH RESULTS, 1980. Stephen

I. Szara. M.D., D.Sc., and Jacqueline P. Ludford, M.S., eds.

A RAUS (Research Analysis and Utilization System) Review Report

on the abuse liability of the benzodiazepine "tranquilizers."

GPO Stock #017-024-01108-8 $5.00 NTIS PB #82-139106 $13

34 PROBLEMS OF DRUG DEPENDENCE, 1980: PROCEEDINGS OF THE 42ND

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. Not available from

NCDAI.

GPO Stock #017-024-01061-8 $8.00 NTIS PB #81-194847 $34

35 DEMOGRAPHIC TRENDS AND DRUG ABUSE. 1980-1985. Louise G.

Richards. Ph.D.. ed. Estimates of probable extent and nature of

nonmedical drug use, 1980-1995, based on age structure and other

characteristics of U.S. population.

GPO Stock #017-024-01087-1 $4.50. NTIS PB #82-103417 $13

185
36 NEW APPROACHES TO TREATMENT OF CHRONIC PAIN: A REVIEW OF MULTIDISCIPLINARY PAIN CLINICS AND PAIN CENTERS. Lorenz K.Y. Ng. M.D.,

ed. Discussions by active practitioners in the treatment of pain.

GPO Stock #017-024-01082-1 $5.50. NTIS PB #81-240913 $19

37 BEHAVIORAL PHARMACOLOGY OF HUMAN DRUG DEPENDENCE. Travis

Thompson, Ph.D., and Chris E. Johanson, Ph.D.. eds. Presents a

growing body of data, systematically derived, on the behavioral

mechanisms involved in use and abuse of drugs

GPO Stock #O17-024-01109-6 $6.50 NTIS PB $82-136961: $25

38 DRUG ABUSE AND THE AMERICAN ADOLESCENT. Dan. J. Pettieri,

Ph.D.. and Jacqueline P. Ludford. M.S., eds. A RAUS Review

Report, emphasizing use of marijuana: epidemiology, sociodemographic and personality factors, family and peer influence,

delinquency, and biomedical consequences.

GPO Stock #017-024-01107-0 $4.50 NTIS PB #82-148198 $14.50

39 YOUNG MEN AND DRUGS IN MANHATTAN: A CAUSAL ANALYSIS.

Richard R. Clayton, Ph.D., and Harwin L. Voss, Ph.D. Examines

the etiology and natural history of drug use, with special focus

on heroin Includes a Lifetime Drug Use Index.

GPO Stock #017-024-01097-9 $5.50 NTIS PB #82-147372 $19

40 ADOLESCENT MARIJUANA ABUSERS AND THEIR FAMILIES. Herbert

Hendin. M.D., Ann Pollinger, Ph.D., Richard Ulman, Ph.D.. and

Arthur Carr, Ph D. A psychodynamic study of adolescents

involved in heavy marijuana use, to determine that interaction between family and adolescent gives rise to drug abuse

GPO Stock #017-024-01098-7 $4.50 NTIS PB #82-133117 $13

41 PROBLEMS OF DRUG DEPENDENCE, 1981: PROCEEDINGS OF THE 43RD

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. Not available from

NCDAI.

Not available from GPO NTIS PB #82-190760 $41.50

42 THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL FLUIDS. Richard L.

Hawks, Ph.D., ed. Varied approaches to sensitive. reliable, and

accessible quantitative assays for the chemical constitutents of

marijuana, for researchers. Not availabie from NCDAI.

GPO Stock #017-024-01151-7 $5 NTIS PB #83-136044 $1643

13 PRQBLEMS OF DRUG DEPENDENCE, 1982: PROCEEDINGS OF THE 44TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. Not available from

NCDAI.

GPO Stock #O17-024-01162-2 $8.50 NTIS PB #83-252-692/AS $40

186
44 MARIJUANA EFFECTS ON THE ENDOCRINE AND REPRODUCTIVE SYSTEMS.

Monique C. Braude, Ph.D., and Jacqueline P. Ludford, M.S., eds.

A RAUS Review Report of animal studies and preclinical and

clinical studies of effects of cannabinoids on human endocrine

and reproductive functions.

GPO Stock #017-024-01202-5 $4. NTIS PB #85-150563/AS $14.50

45 CONTEMPORARY RESEARCH IN PAIN AND ANALGESIA, 1983. Roger M.

Brown, Ph.D.; Theodore M. Pinkert, M.D., J.D.; and Jacqueline P.

Ludford. M.S., eds. A RAUS Review Report on the anatomy,

physiology, and neurochemistry of pain and its management.

GPO Stock #017-024-01191-6 $2.75 NTIS PB $84-184670/AS $11.50

46 BEHAVIORAL INTERVENTION TECHNIQUES IN DRUG ABUSE TREATMENT.

John Grabowski, Ph.D.; Maxine L. Stitzer. Ph.D., and Jack E.

Henningfield, Ph.D., eds. Reports on behavioral contingency

management procedures used in research/treatment environments.

GPO Stock #017-024-01192-4 $4.25 NTIS PB #84-184688/AS $16

47 PREVENTING ADOLESCENT DRUG ABUSE: INTERVENTION STRATEGIES.

Thomas J. Glynn, Ph.D.; Carl G. Leukefeld, D.S.W.; and

Jacqueline P. Ludford, M.S., eds. A RAUS Review Report on a

variety of approaches to prevention of adolescent drug abuse, how

they can be applied, their chances for success, and needed future

research.

GPO Stock #017-024-01180-1 $5.50 NTIS PB #85-159663/AS $22

48 MEASUREMENT IN THE ANALYSIS AND TREATMENT OF SMOKING

BEHAVIOR. John Grabowski, Ph.D., and Catherine S. Bell, M.S.,

eds. Based upon a meeting cosponsored by NIOA and the National

Cancer Institute to delineate necessary and sufficient measures

for analysis of smoking behavior in research and treatment

ettings.

GPO Stock #017-024-01181-9 $4.50 NTIS PB 84-145-184 $14.50

49 PROBLEMS OF DRUG DEPENDENCE, 1983: PROCEEDINGS OF THE 45TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. A collection of

papers which together record a year's advances in drug abuse

research; also includes reports on tests of new compounds for

efficacy and dependence liability.

GPO Stock #017-024-01198-3 $12 NTIS PB 85-159663/AS $22.

50 COCAINE: PHARMACOLOGY, EFFECTS, AND TREATMENT OF ABUSE. John

Grabowski, Ph.D., ed. Content ranges from an introductory

overview through neuropharmacology, pharmacology, animal and

human behavioral pharmacology, patterns of use in the natural

environment of cocaine users, treatment, through commentary on

societal perceptions of use.

GPO Stock #017-020-01214-9 $4 NTIS PB 85-15038l/AS $14.50

187
51 DRUG ABUSE TREATMENT EVALUATICN: STRATEGIES, PRCGRESS, AND

PROSPECTS. Frank M. Tims, Ph.D.. ed. A state-of-the-art review

of drug abuse treatment evaluation, identifying research needs,

promising approaches, and emerging issues.

GPO Stock #017-020-01218-l $4.50 NTIS PB 85-150365/AS $17.53

52 TESTING DRUGS FOR PHYSICAL DEPENDENCE POTENTIAL AND ABUSE

LIABILITY. Joseph V. Brady, Ph.D.. and Scott E. Lukas, Ph.D.,

eds. Describes animal and human test procedures for assessing

dependence potential and abuse liability of opioids. stimulants,

depressants, hallucinogens, cannabinoids, and dissociative

anesthetics.

GPO Stock #017-024-0204-1 $4.25 NTIS PB 85-15O373/AS $16

54 MECHANISMS OF TOLERANCE AND DEPENDENCE. Charles Wm. Sharp,

Ph.D., ed. Review of basic knowledge concerninq the mechanism of

action of opiates and other drugs in producing tolerance and/or

dependence.

GPO Stock #017-024-31213-1 $8.50 NTIS PB No. to be assigned.

55 PROBLEMS OF DRUG DEPENDENCE. 1984. PROCEEDINGS OF THE 46TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE. INC. Louis S. Harris, Ph.D., ed.

IN PRESS OR PREPARATION

53 PHARMACOLOGICAL ADJUNCTS IN SMOKING CESSATION

John Grabowski. Ph.D.. ed.

56 ETIOLOGY OF DRUG ABUSE: IMPLICATIONS FOR PREVENTION. Cory1

LaRue Jones, Ph.D., and Robert J. Battjes. D.S.W.. eds.

57 SELF-REPORT METHODS OF ESTIMATING DRUG USE: MEETING CURRENT

CHALLENGES 10 VALIDITY. Beatrice A. Rouse, Ph.D.. Nicholas J.

Kozel, M.S., and Louise G. Richards, Ph.D., eds.

59 CURRENT RESEARCH ON THE CONSEQUENCES OF MATERNAL DRUG ABUSE

Theodore M. Pinkert, M.D., J.D., ed.

60 PRENATAL DRUG EXPOSURE: KINETICS AND DYNAMICS. C. Nora

Chianq. Ph.D.. and Charles C. Lee. Ph.D., eds.
DHHS Publication No. (ADM) 85-1401

Printed 1985