- Longer stays in alcohol and drug treatment lead to better post-treatment results.
- Factors leading to a successful stay in treatment seem to differ by gender.
- For women, staying in treatment was predicted by being unemployed, being married, having higher incomes, and having lower levels of psychiatric severity relative to those who dropped out.
- For men, staying in treatment was predicted by being older, receiving employer pressure to enter treatment, and having a goal to abstain from drinking and drug use.
"Just as one or two treatments for cancer is not sufficient," explained Jennifer R. Mertens, a researcher with the Kaiser Permanente Medical Care Program and lead author of the study, "having a few visits to alcohol and drug treatment is less effective than treatment over a longer period of time. Much of alcohol and drug treatment is about learning new behaviors and coping styles - learning new, more effective ways to cope with family/work problems, learning how to communicate more assertively, and education regarding the harmful medical consequences of alcohol and drug abuse. Accordingly, reinforcement over a longer time period is beneficial. In addition, a longer time in treatment allows people to develop social support systems and friendships among people who are not drinking and/or using drugs, and who support their recovery."
"Substance use disorders develop over an extended period and are not readily resolved," concurs John Finney, director of the Program and Evaluation Center at the VA Palo Alto Health Care System. "'Recovery' is a protracted process, involving extensive social, psychological, physiological and/or spiritual change. At least for some individuals, more extended treatment may be necessary for these changes to occur. Treatment retention and patient factors may operate together in a dynamic way to produce better patient outcomes." In addition, factors that influence treatment retention may differ by gender.
Mertens described previous studies of men and women enrolled in public treatment programs. Factors that enhanced the risk of dropout for men were largely structural or sociological, such as homelessness, the absence of pressure from the legal system, lower income levels, and less social stability (for example, they were separated or divorced). For women, dropout chances were enhanced if they needed services that were not provided in treatment, believed their health was due to chance more than personal responsibility, and had a poor self-image. Yet not only did these studies look at a relatively small number of women, they also looked largely at clients in public, inpatient treatment.
"These clients are generally uninsured and of lower socio-economic status than clients in private treatment programs, most of whom are insured or can afford treatment" said Mertens. "Thus, the risks for dropout may be different among the clients in these prior studies than for clients enrolled in private, outpatient treatment - which is the predominant mode of treatment in the U.S. today."
The study found that, for both men and women, those with fewer and less severe drug problems tended to stay in treatment longer. Conversely, and somewhat ironically, those with more severe drug problems had shorter stays. Otherwise, there were clear gender-specific differences among predictors of treatment retention.
"Among women," said Mertens, "staying in treatment was predicted by being unemployed, being married, and having higher incomes. On the other hand, dropping out was linked to being African-American and having higher levels of psychiatric severity compared to those who remained in treatment longer. Among men, staying in treatment was predicted by being older, receiving employer pressure to enter treatment, and having a goal to abstain from drinking and drug use. On the other hand, dropping out was linked to just the opposite of these predictors, such as being younger, no employer pressure, and no abstention goal."
Finney noted that the study addresses several important issues. "First," he said, " it conveys the fact that many individuals drop out of substance abuse treatment. Multiple treatment episodes may be needed for the recovery of some individuals. Second, it indicates that the likelihood of remaining in treatment varies for different individuals (for example, those with less severe versus more severe drug problems). In short, everyone does not enter treatment with an equal chance of remaining in treatment. Third, this article also points out that the characteristics associated with individuals staying in treatment longer differ, in many respects, for men and women."
Both Mertens and Finney believe the study's findings clearly point toward a need for gender-specific research and programs, as well as a need to avoid generalizing findings from public populations to private or insured populations.
"This study raises the possibility that one, findings regarding predictors of treatment retention may have been diluted in previous studies that used a combined sample of men and women," said Finney. "Different patient factors predict retention for men and women. Accordingly, gender-specific treatment programs and/or gender-specific treatment retention interventions may be needed to enhance the likelihood that men and women will remain in treatment. Two, findings based on data from public program samples may not generalize to private, HMO populations."
Mertens sees both professional and practical applications to the study's findings. "Clinicians may be able to identify patients who are at risk of dropping out of treatment," she said. "Providers might offer some psychiatric services or psychiatric referrals for women with psychiatric problems, or motivational enhancement therapy for men who need to increase their motivation levels. Furthermore, people who are entering treatment, as well as their families and friends, may benefit by becoming aware of those 'risk factors' associated with dropping out and plan accordingly."
The co-author of the Alcoholism: Clinical & Experimental Research paper was Constance M. Weisner of the Division of Research at Kaiser Permanente Medical Care Program, and of the Department of Psychiatry at the University of California-San Francisco. The study was funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.
Contact: Jennifer R. Mertens
jrm@dor.kaiser.org
510-450-2167
Kaiser Permanente Medical Care Program
Add'l Contact: John Finney, Ph.D.
john.finney@med.va.gov
650-493-5000 x22848
VA Palo Alto Health Care System