Program structure and counselor-client contact in outpatient substance abuse treatment.

Clients tend to have better treatment outcomes when more counseling sessions (Fiorentine and Anglin 1996, 1997) and case management services (McLellan et al. 1999) are provided and when counselor caseloads are low (McCaughrin and Price 1992; Woodward et al. 2006). While the ideal is to provide appropriate personal contact hours and lower client-to-counselor ratios, programs experience pressures from funding sources and monitoring organizations to do more with less, and cuts are often made in personnel and in nonsubstance abuse specific services (Hubbard et al. 1989; Etheridge et al. 1995). When treatment providers must make do with fewer personnel, the number of counseling sessions available to clients may decrease, and counselors may be required to take on more clients in groups, further impacting personal contact between counselors and clients. Viewing a treatment program as an “open system”—that is, it is not completely self-sufficient, but interacts with its environment (see Pfeffer and Salancik 1978)—provides a framework for understanding the way counselor–client contact is structured. Specifically, the external environment can be a source of uncertainty and a source of resources, which can shape decisions about programs' internal organization and management (Robey and Sales 1994). Accrediting bodies are one such external force, promoting high-quality programming as assessed by an independent, external group. Guidelines applied by accrediting bodies reflect important aspects of treatment, including the frequency of sessions, types of services provided, and amount of direct contact with staff. For instance, accredited agencies provide more treatment hours (Lemak and Alexander 2005), and are more likely than nonaccredited programs to provide mental health (Friedmann, Alexander, and D'Aunno 1999) and medical services (Durkin 2002). An equally important element of a program's environment is its clientele. Clients with different needs may require different treatment plans (National Institute on Drug Abuse 1999), and appropriate services will often be negotiated as part of referral and contract decisions. Programs that admit clients with distinctive needs are more likely to provide specialized services (Olmstead, White, and Sindelar 2004), including case management, which has been found to be predictive of positive posttreatment outcomes (McLellan et al. 1999). Likewise, having a high proportion of criminal justice (CJ) clients can prompt modifications in the way counselors utilize their time with clients. The number of CJ referrals to community-based treatment programs is increasing (Office of Applied Studies 2004), and are often accompanied by funds and mandates. Thus, programs may alter services to meet expectations of CJ referral sources. Program ownership also has implications for contact. Generally speaking, public programs tend to provide more supplemental services than do privately owned programs (Friedmann, Alexander, and D'Aunno 1999; Rogers and Barnett 2000), and the for-profits tend to offer fewer medical and social services (Friedmann, Alexander, and D'Aunno 1999). Lemak and Alexander (2005) found that public programs tend to have higher caseloads, but did not find an association between ownership and counseling hours. It appears that publicly owned programs offer a wider range of supplemental services with fewer staff (as evidenced by higher caseloads) than their privately owned counterparts. Whether or not ownership is associated with counseling hours is unclear. Factors that are internal to the program, reflecting its specific design and operations, are also relevant to understanding counselor–client contact. Programs that are part of a larger “parent” organization often can shift staff from one location to another within the organization to respond to client needs or market demands, or hire specialized personnel who work part-time at multiple locations (Davis-Blake and Uzzi 1993). For these reasons, operating within a parent organization is associated with greater service provision (Durkin 2002), particularly with regard to medical and mental health services (Friedmann, Alexander, and D'Aunno 1999). Affiliation with a mental health center is related to providing more counseling hours and offering smaller caseloads (Lemak and Alexander 2005). However, programs affiliated with a parent organization also tend to serve more clients (Substance Abuse and Mental Health Services Administration 2003). Turnover among staff is a significant problem in substance abuse treatment programs (e.g., Alcoholism & Drug Abuse Weekly 2002; Gurel et al. 2005), and staff changes can have implications for conducting clinical activities. The amount of counselor–client contact can be quite different in programs where the majority of counselors are new to the organization, compared with those where counselors have been with the program for several years. When a counselor quits or is terminated, his or her caseload must be redistributed among staff, resulting in higher caseloads until the position is filled. Time spent locating, hiring, and training replacement or new staff may result in a temporary disruption in contact. The current study extends the existing literature by using a naturalistic design to examine structural correlates of counselor–client contact in outpatient (nonmethadone) substance abuse treatment programs, while simultaneously controlling for geographical differences. Specific aspects of the external environment and internal organization are expected to predict counselor–client contact.