Dropping out of substance abuse treatment: A clinically oriented review

Clinxal PsychologyR&w, Vol. 12, pp. 93-116, 1992 Printed in the USA. All rights reserved.

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DROPPING OUT OF SUBSTANCE ABUSE TREATMENT: A CLINICALLY ORIENTED REVIEW Michael 1. Stark Lewis & Clark College

Early

ABSTRACT. dramatically abuse

from

treatment

clients.

in treatment. treatment dures

dropout

Evidence

The

history,

effects

regarding

of client

retention

motivation,

in treatment

and when they are seen in smaller such as reminder

phone

from substance and constitute

groups

in friendly,

prevention

of substance as untreated

variables

on continuation

legal pressure, prior

and

of treatment factors

located,

smaller, initial

comfortable

letters can be employed

and proce-

decentralized

have lower attrition rapid

rates do not differ

the same outcome

criminality

An analysis

they receive

calls and personal

needed to mount more extensive attrition

use,

although

The consequences

and social

expenditures,

longer when

techniques

Dropouts

substance

that more conveniently

attention,

having

of demographic

are also examined.

indicates

is very high,

treatments.

with earb dropouts

staff ratios and more per capita

to continue

the clinician,

abuse treatment

and psychiatric

the impact

and psychopathology

used to enhance likely

substance

in medical

are severe, however,

is considered

with higher clinical also

attrition from

those found

rates.

clinics,

Clients

are

response and individual environments.

Inexpensive

in the absence

of resources

interventions.

abuse treatment

fare poorly,

are a source of frustration

a major expense for treatment

organizations.

for

The purpose of

this paper is to examine the research on dropping out of substance abuse treatment, including the prevalence and consequences of dropping out, characteristics of the client and aspects of the clinic and treatment regimen that affect retention, and interventions to reduce premature termination. This review will confine substance Combining

abuse to alcohol and illicit drugs and omit nicotine.

drug and alcohol abuse is consistent

with the increasing

recognition

of the

interrelationships of the substance abuse disorders (Battjes, 1988) and the considerable degree of merger between alcohol and drug treatment strategies and even facilities (National Institute on Drug Abuse, 1983). Although nicotine dependence has many of the same attributes as other forms of substance abuse (Battjes, 1988; Department of Health and Human Services, 1988; Jasinski, Johnson, & Henninglield, 1984; Kozlowski et al., 1989), attrition from smoking cessation programs will not be included because these

Correspondence

should

ing Psychology,

Box 93, Lewis

be addressed

to Professor

& Clark

College,

Michael Portland, 93

J. Stark, OR

Graduate

97219.

Program

in Counsel-

sa

hf. J. Stark

programs are time limited, typically entailing only 4-10 sessions (Department of Health and Human Services, 1988), and their attrition rates are considerably lower than those found in alcohol or drug abuse treatment (Barnes, Vulcano, & Greaves, 1985; Curry, Marlatt, Gordon, & Baer, 1988; Janis & Hoffman, 1970; Kamarck & Lichtenstein, 1988; Powell & McCann,

198I).

PREVALENCE As part of an extensive review of attrition from medical and psychiatric treatments, Baekeland and Lundwall (1975) reached the following conclusions about heroin addicts: (a) 2668%

terminated

from outpatient

and 23-39s

quit inpatient

detoxification

pro-

grams; (b) about 80% dropped out within the first 3 months of treatment at drug-free outpatient clinics; and (c) over 50 % of applicants for methadone maintenance left during the initial

orientation.

They

also determined

that

52-75s

of outpatient

alcoholics

dropped out by the fourth session. Recent investigations of substance abuse treatment have disclosed high dropout rates (see Table 1). Meaningfully summarizing these prevalence data is difficult because researchers define dropout differently, in part due to divergent expectations of participation across treatment modalities. In spite of the difficulties, initial dropout rates for substance abusers

are clearly

unacceptable,

with a majority

of investigators

finding

over 50%

attrition within the first month of treatment. These rates, however, are not much higher than the 30&O% dropout range found with general outpatients in community mental health centers (Pekarik, 1983a) or the 50-80s d ro p ou t range found in medical treatment (Meichenbaum & Turk, 1987). In a study of nearly 1 million clients who consulted a psychiatrist, the average number of visits was 4.7 (National Center for Health Statistics, 1966), the exact average found with alcoholics (Leigh, Ogborne, & Cleland, 1984). Even in private practices of psychologists and psychiatrists with educated and well-off clients, 63-65 % of clients terminate

before the tenth session, and the median number of sessions

attended is between four and five (Garfield, 1986). The comparability of attrition rates across different client populations suggests caution in interpreting substance abuse dropout as unique approaches

and points to the utility of seeking

for premature

generic

explanations

and treatment

termination.

CONSEQUENCES Although it seems obvious, than treatment completers.

OF DROPPING

OUT

it cannot be assumed that dropouts have poorer outcomes In a review of the psycho~erapy literature, Orlinsky and

Howard (1986) concluded that improvement in psychotherapy is proportionally greater in the eariy sessions, indicating that clients who drop out after a few sessions may gain the bulk of treatment advantage. Many psychotherapy dropouts reported no additional need for services (Pekarik, 1983b) or expressed satisfaction with the services they received (Silverman & Beech, 1979). In one study (Pekarik, 1983a), it was found that although 30.8% of the single-session dropouts were actually worse at follow-up, dropouts who attended three or more sessions had approximately the same improvement rate as therapist-rated appropriate terminators (i.e., 75% for dropouts who attended three or more sessions and 76.9% for appropriate terminators), Clients who dropped out after two visits obtained a level of improvement halfway between the one and three or more session dropout groups. Pekarik points out that although his data demonstrate that some dropouts do well, those who terminated after only one session did worse than clients in

95

Dropping Out of Substance Abuse Treatment

TABLE

1. Prevalence of Dropping Out: Recent Studies Findings

Clients

Authors

Alcoholism Gordis,

Dorph,

Sepe, &

Over 5,000

admissions

hospital-based

Smith (1981)

treatment

45 % termination

to a

rate within

the first month.

treatment

program Leigh,

Ogborne,

& Cleland

(1984)

132 male and 40 female

15% kept no appointments;

outpatients

38%

kept 1-2;

19% kept 3-5;

13% kept 6-7;

and only 28%

kept 8 or more. Rees,

Beech,

& Hore (1984)

100 consecutive hospital

referrals

alcoholism

to a

46%

did not come for the

initial interview;

treatment

attending

unit

did not return Rees (1986)

& Glaser (1987)

of those

again.

92 male and 25 female new

35%

admissions

initial visit, and another

to an alcoholism

failed to return after the

dropped out within

clinic Silberfeld

44%

the initial interview

364 alcohol-

83 % attrition

or

narcotic-abusing

months;

outpatients

18%

1 month.

in the first 3

95 % attrition

within

the first year. Drug abuse treatment Steer & Kotzker

(1978)

1,2 16 methadone

maintenance

47 % left AMA during their first admission

clients

episode;

59%

left AMA during their second. Simpson

(1) 455 DARP

(1981)

Reporting drug-free

outpatient

therapeutic

clients

(3) 398 DARP

methadone

clients outpatient

detoxification-only 110 admissions drug-free DeLeon

& Schwartz

(1984)

Gossop, Johns,

& Green

(1987)

74%

were expelled

24%

completed

64%

were expelled

64%

clients for outpatient

(1988)

Stark,

Campbell,

Brinkerhoff

&

(1990)

or quit;

treatment.

completed

to seven

12-month

communities

ranging

treatment.

retention

24%

patients

of the outpatients

100 consecutive

admissions

to

drug counseling

117 consecutive

callers making

an initial appointment abuse counseling

for drug

26%

rates

from 4 % to 12 %

54 opioid detoxification

outpatient

or quit;

treatment.

were expelled

18.2%

or quit;

treatment.

32 % completed

of the inpatients

complete Stark & Campbell

or quit;

treatment.

counseling

982 admissions therapeutic

completed

15 % completed

(4) 135 DARP Steer (1983)

20%

clients

(2) 382 DARP community

72 % were expelled

(Drug Abuse

Project)

and 83%

failed to

the program.

remained

active after 1

month. 50% forms;

picked up the application 11% continued

treatment

in

after 1 month.

96

M. J. Stark

untreated or minimally psychotherapy literature Results

of research

treated groups and had some of the poorest (Pekarik, 1985). with substance-abusing

tween dropping out and negative outcome.

outcomes

clients depict a powerful

RaekeIand

in the

association

be-

and Lundwall found that dropouts

from inpatient or outpatient alcoholism treatment have worse outcomes than program completers and that alcoholics who terminate treatment before 6 months of sobriety are unlikely to maintain improvement. Walker, Donovan, Kivlahan, and O’Leary (1983) determined

that 70.2 % of alcohalics who completed

an aftercare

program

were abstinent

at a S-month follow-up, compared to only 23.4 % of those who dropped out of aftercare. The picture is similar for drug abusers. Compared to dropouts, addicts who completed detoxification, therapeutic community, or methadone maintenance treittment were much more likely to be drug and alcohol free, have lower unemployment

and arrest rates, cease

intravenous drug use, and have lower relapse rates (Aron & Daily, 1976; Ball, Lange, Myers, & Friedman, 1988; Berger & Smith, 1978; Perkins & Bloch, 1971; Raynes, Patch,

& Fisch,

1972).

Simpson

and his colleagues

(Simpson,

1979;

Simpson,

$981;

Simpson, Savage, & Lloyd, f979) found that Drug Abuse Reporting Project (DARP) clients in drug-free and therapeutic communities who campleted treatment had more favorable outcomes than those who were expelled or quit. In contrast, with methadone clients the type of termination (quit or expelled, completed treatment, or referred or other) had no effect after time in treatment was statistically controlled. The idea that time in treatment is an important predictor variable, whether a client drops out, receives some support in the alcoholism

irrespective

literature

of

and greater

confirmation in other substance abuse research. O’Leary, Rohsenow, and Chaney (1979) found a positive correlation between duration of alcoholism treatment aftercare and employment, time elapsed to the first drinking episode, and number ofdrinking days during a S-month foliow-up. Welte, Haynes, Sokolow, and Lyons (1981) established that patients who remained abstinence

in inpatient

rates 8 months

alcoholism

after treatment

treatment

longer than 60 days had higher

than those who stayed for a shorter time. found that length of stay was only sometimes

However, Finney, Moos, and Chan (1981) related to alcoholics’ outcomes; Walker et al. (1983) cited a number of experimental studies reporting no relation between the length of alcoholism treatment and outcome, especially if measured

at 2 years post-treatment.

Length of stay in therapeutic communities has been shown to correlate with decreased indicators of psychopathology (Sacks & Levy, 1979) and increases in abstinence, number of months of employment, and reductions in criminal activities (D&eon & Andrews, 1978; Wolland, 1978). Furthermore, DARP data indicate that for methadone maintenance,

therapeutic

community,

and drug-free

outpatient

clients,

only lengthy treatment

tenure was associated with long-term improvement (Simpson, 1979; Simpson, 1981; Simpson et al., 1979). Specifically, clients had more favorable outcomes if they were in treatment over 90 days; those in treatment less than 90 days had no better outcomes than detoxification- or intake-only clients. A positive linear relation between time in treatment and outcome was also found, but only for clients in treatment over 90 days. Another result was that 57% of the total sample had at least one post-DARP treatment episode. Using only the first post-DARP episode in the analysis, it was established that additional methadone maintenance or therapeutic community treatment was related to improvements in employment and drug use and that longer term post-DARP treatment was correlated with the most favorable outcomes. In summary, ahohol and drug treatment completers have better outcomes than dropouts except in methadone maintenance, where the type of termination is not related to follow-up status once Iength of time in treatment is controlled. Length of time spent in a

treatment outcome

episode is moderately for drug abusers.

related to outcome

These

for alcoholics and strongly related to

results are very different

from those in the general

psychotherapy literature, which reveal rapid gain from brief treatment episodes, even for clients who drop out as early as the third session. Thus, because of their high initial attrition rates, very few substance-abusing clients receive the potential benefit from treatment, and once having dropped out, most suffer relapse and its attendant

ills.

CLIENT FACTORS

The

literature

is replete

with studies examining

demographic

correlates

of substance

abuse treatment dropout. Although the results have not yielded a reliable profile of the dropout, these studies can suggest interventions that may prevent premature termination. Age. Baekeland

and Lundwall (1975) concluded

that younger age was moderately

related

to dropping out. They postulated that young age is associated with greater geographic mobility and a reduced likelihood of having a nuclear family or other community ties that might stabilize the client and support the treatment effort. Within correlated

methadone

treatment,

some investigators

with time spent in treatment

have found that age was positively

and whether a client quit or was expelled (Ball et

al., 1988; Brown, Watters, Inglehart, & Akins, 1982/1983; Joe & Simpson, 1975; Joe et al., 1982; Sorenson, Gibson, Bernal, & Deitch, 1985). However, several of these studies contain methodological difficulties that render their outcomes equivocal. For example, Joe et al. combined young age and being single into one variable and found that “young-single” was related to attrition; yet in light of the apparent relationship of social isolation to treatment dropout (Baekeland & Lundwall, 1975), it is unclear if it was the “young,” the “single,” or the combination that produced the result. Sorenson et al. determined that age was related to dropout in one stage of a several-stage treatment process but not as an overall finding. The Brown et al. correlation was only .15 and attained statistical significance due to the study’s large number of subjects. Furthermore, in a review of 10 studies assessing the effect of age on retention in methadone maintenance, Szapocznik and Ladner (1977) concluded that some studies showed that older patients tend to be retained, while other studies found no relation; another study determined that younger patients had higher retention rates (Babst, Chambers, & Warner, 1971). Therefore, there is some evidence that young age relates to termination of methadone treatment, but the association is not consistent or powerful. As in the case of methadone treatment, there is a moderate

empirical

relation between

young age and attrition from alcoholism treatment. Positive correlations have often been found between age and retention (Leigh et al., 1984; Linn, 1978; Noel, McCrady, Stout, & Fisher-Nelson, 1987; Rees, Beech, & Hore, 1984; Steer, 1983a), although some negative results have also been reported (Beckman & Bardsley, 1986; Fink, Rudden, Longabaugh, McCrady, & Stout, 1984). Studies of drug-free treatment also produced mixed evidence. Generally, younger age has been found to be associated with dropout from drug-free outpatient treatment (Beck, Shekim, Fraps, Borgmeyer, & Whitt, 1983; Feigelman, 1987; Harford, Ungerer, & Kinsella, 1976); however, some studies find no correlation (Stark & Campbelf, 1988; Steer, 1983b). Evaluations of inpatient drug-free programs yielded no association between age and retention (Aron & Daily, 1976; McFarlain, Cohen, Yoder, & Guidry, 1977; Robinson & Little, 1982).

hf. J. Stark

98

In summary, several recent studies have reported that younger age is linked to higher substance abuse dropout rates, especially in methadone and alcoholism treatment; but there are many conflicting results, a fact consistent with Garfield’s (1986) conclusion that age is not an important factor for continuation in general psychotherapy. When found, the association between young age and attrition is possibly due to the anomie, impulsivity, and heightened substance use of youths. These factors are difficult to counter, although peer group treatment or treatment that employs age-similar therapists (Beutler, Crago, & Arizmendi, 1986) or involves clients’ social support (Feigelman, 1987; Weidman, 1987) has proved to be helpful in retaining and treating younger clients. Gender.

Baekeland

and Lundwall

found gender to be related to dropping

out of treat-

ment in 13 of 29 (44.8%) studies and concluded that females were more apt to drop out than males. They reported that this association seems especially valid in substance abuse treatment, where it was explained by the “. . fact that alcoholism and addiction in women implies a greater degree of social deviancy than in men . . .” (Baekeland & Lundwall, 1975, p. 763). Garfield (1986) noted that a majority of investigators have found no differences between the sexes in psychotherapy retention; and although he discovered some studies showing a slight trend favoring males in continuation, he concluded that “. . on the whole, it does not appear that sex is an important predictor of continuation in psychotherapy . .” (p. 221). Research with substance-abusing clients tends to confirm Garfield’s generalization. Investigators have found no relation between gender and retention with methadone (Joe et al., 1982; Steer & Kotzker, 1978), alcoholic (O’Leary, Calsyn, Chaney, 1977; Rees et al., 1984; Silberfeld & Glaser, 1978), or polydrug-abusing

& Freeman, outpatients

(Beck et al., 1983; Stark & Campbell, 1988; Steer, 1983b). Although there are limited main effects, complex relations between gender and retention have been reported. Greene and Ryser (1987) found an interaction between gender, treatment

tenure,

and treatment

longer time in detoxification, ities. Aron and Daily (1976)

modality

such that women

tended

to spend slightly

hospital, drug-free outpatient, and day treatment modalfound that both males and females with fewer years and

milder levels of drug use and who had outside pressure tended to complete treatment at a higher rate than their counterparts who had entered the program voluntarily with more years of use, heavier current use, and more prior jail time. However, it was found that this relation was stronger for men than for women and that males with a family history of drug or alcohol abuse tended to drop out, but family history was unrelated to completing treatment for women. Beckman and Bardsley (1986) f ound that variables associated with higher retention for women were the belief that a person’s health is not controlled largely by chance and the reporting

of more provided health services.

For men, variables related

to retention were being employed, having a more prestigious occupation, being married, having a larger number of children, and having children ages 5-17 who lived with them and for whom they had some source of child care. Men also remained in treatment longer if they had less prior treatment, lower alcohol consumption, less pathological drinking, lower self-reported depression, and higher self-efficacy regarding the use of alcohol. Taken together, these results do not support Baekeland and Lundwall’s assertion that gender directly affects retention, but instead they point to complex relations between gender, social and personality factors, treatment modality, and dropping out. For women, the important factors in retention were their health beliefs, the extent to which they considered programs providing the services they needed, and treatment modality. Attrition for men was influenced more by extratreatment variables, such as their own and their family history of substance abuse, their current social support and social stabil-

ity, and, somewhat lower self-efficacy treatment originally

sarprisingiy,by

scores concerting

perstmbiity substance

factorssuch

use, Beckman

as higher depression and Bardsley

and

surmise that

variables are more important for women because treatment approaches were developed to serve a predominantly male clientele and may not be serving

women’s needs adequately. This implies that clinics that assess and respond to WONTS needs might reduce females’ early attrition. The fact that variables reflective of drug use, personality probIems, and social stability are related to treatment

completion

more strongly

for men than women

might be ac-

counted for by asstrming the following: (a) a more restricted range of substance abuse occurs in women than men; (b) higher depression and lower self-esteem are less disruptive in substance abuse treatment for women than men (supported, in part> by the findings that men with a diagnosis of major depression did worse in ~~ohol~~rn treatment than men without depression and that having a major depression was a positive prognostic indicator in the treatment of alcoholic women [Rounsaville, Dolinsky, Babor, & Meyer, 19871); and (c) men require more social stability to continue with their commitment to treatment than do women. These hypotheses are tentative and untested. It is also important to note that when interactions between gender, dropout, and other variables are reported, the small magnitude of the results and the emergence suggest that gender is not a powerful factor in retention.

of few significant

relations

Social Fa~t~fs. Baekdand and Lundwall determined that Gent “social isolation and unaffiliation” (measured by marital status) was associated with treatment in all of 19 studies considered. A second category, “social stability,” consisted of oe&npational, marital, and residential information. In 20 of 41 studies, Iess socially stable patients tended to terminate prematurely. A third related category, “socioeconomic stat& (SES), was measured by education, income, or occupational status, and w;ts related to dropping out in 35 of 57 investigations. These three categories overlap cansiderably, with marital status counting in social isolation

and social stability,

and occupatianal

information

counting

in social

stability and SES. Logically, the three categories collapse into two, allowing a separate examination of the effects of social isolation and SES, Social

isohition.

Social isolation should be measured

by a widespread

analysis of cfi-

ents’ family ties, friendships, and social involvement in the community. This is especi&y true in the area of substance abuse, where peer influence is particularly strong in the development and maintenance of the deviant use of substances (Elli~t~ Huizing;i, & Ageton, 1985). ~~~f~~~~ate~~~ most inquirers define social isolation exclusively in terms of marital status, althangh some include the impact of having children at home. Fewer researchers look at measures of client satisfaction with their social support, none evaluate the effects of friends and community involvement.

and virtually

There are mixed findings relating marital status to dropout in both alcohol and drug treatment. For alcoholics, some researchers have found that being married or living with one’s spouse (Noel et al., 1987; Zax, Marsey, & Biggs, 1961) or better marital adjustment (Locke & Wallace, 1959) was associated with greater retention, while others have failed to find a correlation between marital status and retention (Rees et al., 1984). However, the value of the Noel et al. results is questionable due to the requirement of sponsal ~art~~~~ation in treatment. Regarding itlicit drug use, Stark and ~arn~~~~l (1988) and Steer (1983b) determined that marital status was unrelated to completing ~~~trne~t in investigations of outpatient drug-free clients, In methadone treatment, some investigators have found a correintion between being single and dropping out (Joe et al.) 1982; Sorenson et al., 1985), although

M. J. Stark

100 Szapocznik

and Ladner

(1977)

reported

mixed

findings

in their review.

It should be

noted that in Joe et al., single and young were confounded, and in Sorenson et al., the treatment program required a sponsor (who could have been a spouse), which created an implicit advantage for married clients. Generally, being married is only mildly associated with greater retention in alcohol and drug treatment, and even that effect may be a function per se.

of spousal support for the treatment

effort rather than a result of social support

One study showed that having children in the home improved retention in a pediatric clinic that provided long-term care to children who were exposed in utero to the substance abuse of their mothers (Ghan, Wingert, Wachsman, Schuetz, & Rogers, 1986). In alcoholism counseling, this effect has sometimes been found for men and women (Leigh et al., 1984) and sometimes only for men (Beckman & Bardsley, 1986). Social support, more broadly defined, correlates with continuation in alcoholism treatment. Dropouts’ scores on the FIRO-B (Fundamental Interpersonal Relations Inventory-Behavior,

Ryan,

1970) indicated

that they manifested

a stronger need for attention

and support and had deeper feelings of social isolation and loneliness (Cummings, 1977). Beckman and Bardsley (1986) noted that social support for treatment correlated with treatment alcoholics outpatient

completion for men but not women. Family participation in the treatment of has been shown to affect continuation; that is, clients were retained longer in treatment

if they had been assigned to couples or family interventions

pared to those assigned to individual or group treatment (Smart Peer group treatment can be viewed as implicitly enhancing port. Kofoed,

Tolson,

peer group treatment

Atkinson, improves

Toth, retention

and Turner

(1987)

com-

& Grey, 1978). cohesion and social sup-

have shown that age-similar

with older (ages 55-66)

VA outpatient

alcohol-

ics. They found that clients in age-similar groups stayed in treatment longer (9 vs. 5 months), had fewer irregular discharges (5 vs. IS), and were more likely to complete 1 year of treatment compared to clients in mixed-age “historical” control groups. They describe the age-similar groups as having rapidly evolved processes of socialization and support, with a slower pace of interaction

and less confrontation

than seen in mixed-age

groups.

This study should be viewed cautiously because it did not employ a true experimental design and the afternoon scheduling of the age-similar groups might have been more convenient for elderly clients compared to the evening time of the mixed-age groups. There are varied effects of family pressure on treatment retention with adult clients 1987) and positive results with adolescents (Feigelman, 1987; Weidman, (Weidman, 1987).

Feigelman

found that completion

rates for multiple-drug-using

adolescents

day treatment setting were 33% if both parents were involved in the treatment 10% if father only, 5% if mother only, and 0% if neither parent was involved.

in a

process, Another

result was that when parents were described as mutually sharing the child’s discipline, 50% completed treatment, versus 16% when the father and 10% when the mother was depicted as the primary disciplinarian. Maternal mental health and treatment history also affected dropout rates. The children of mothers who had no mental health problems or treatment history had a completion rate of 10 % , while those with mothers reporting mental health problems and no treatment history or current treatment had retention rates of 0%. Interestingly, children of mothers who had a history of mental health problems and a treatment history had a retention rate of 23 % , more than double that of the children with “well” mothers. The same trends were found for the fathers, but the results did not achieve statistical significance. These data imply that families with a positive treatment history, or who participate in the treatment of the target client, will help in the retention of that client. at least when the client is an adolescent.

Afthougb attrition

investigators

can be reduced

generally

confirm

by engaging

Baekeland

and Lundwall’s

the help of clients’ significant

conclusion

others,

that

this is only

true to the extent that others support treatment. Social influence can also be negative; for example, Feigelman discovered that if clients had older brothers, their completion rates were 6% in contrast to 17% for those without older brothers. In addition, Sorenson et al. (1985) found that requiring a family member or other person to sponsor treatment increased dropout during the application process for methadone maintenance treatment. Sorenson et al, indicated that few clients had trouble finding a sponsor, and few dropped out when the presence of the sponsor was required, but many sponsors were unwilling to help or became hindrances to client resolve. Thus, clinicians would do well ta be selective in their recruitment of others to support treatment because they have proven to be potent~aIly as damaging

as they can be supportive

of client continuation.

Socioeconomic status. Baekeland and Lundwafl defined clients’ SES by their education and income/occupational status and determined that lower social class status positively correlated

with dropout.

Evidence

from recent studies of continuation

in general

psychotherapy is consistent with this conclusion {Garfield, 1986), as are results from substance abuse studies. Beckman and Bardsley (1986) established that higher income, insurance,

and treatment

retention,

as were employment

in a private

institution

were related to alcoholism

and occupational

prestige

for men only.

treatment

Employment

and occupational level have been found to be related to completion of an alcoholism driving-under-the-influence (DUI) program (Steer, 1983a), a couples alcoholism program (Noel et al., 1987), and methadone maintenance programs (Ball et al., 1988; Szapocznik & tadner, 1977). Furthermore, Feigelman (1987) found that the occupational level of fathers of adolescents in day-care treatment was refated to retention, with 22 % of patients with manageriallprofessiontiproprietor fathers having completed treatment versus 9% of those with lower level white-collar

fathers and 5% with fathers in blue-collar

occupations. Nevertheless, some researchers report no association between employment tion (Steer, 1983b), while others find employment to be positively correlated ping out (Stark

& Campbell,

1988; Steer & Kotzker,

picture derives from an interaction

between income,

1978; Verinis, employment,

1986).

and retenwith dropThis mixed

and ease of receiving

treatment; that is, when high SES makes receiving treatment easier, as in the case of income and insurance, then it improves retention. When a socioeconomic factor makes attending more difficult, however, as in the case of employment that produces scheduling conflicts, then the outcomes are muddied, These findings suggest that ease and availability of treatment

are the key factors underlying

the data on SES.

Baekeiand and Lundwall found educational attainment related to retention in methadone treatment. However, Garfield (1986) concluded that although education level appears to be somewhat correlated with c:ontinuation in psychotherapy, there is limited agreement across studies, and the association of education with retention possibly occurs only in clinics with rigorous

admission

standards.

In substance

abuse treatment,

education

level

or measured intelligence was not related to attrition from outpatient drug-free (Stark & Campbell, 1988; Steer, 1983b), methadone maintenance (Ball et al., 1988; Szapocznik & Ladner, 1977), or residential (Aron & Daily, 1976; McFarlain et al., 1977; Robinson & Little, 1982) treatment. The fact that these variables do not predict retention supports the previous assertion that the longer treatment tenure associated with higher SES derives form rhe resource (e.g., income, insurance) component of SES. Thus, making treatment more accessible and less expensive might reduce the dropout rates of poorer clients.

102

M. J. Stark

Race. Although Garfield (1986) f ound some evidence of a relation between race and early termination from psychotherapy, with a tendency for African-Americans to terminate more frequently than Caucasians, he cited other conflicting results and criticized most investigators for failing to control for socioeconomic factors that confound with race. Substance abuse treatment research has likewise produced studies finding a higher attrition rate for African-Americans

mixed results, with some (Robinson & Little, 1982;

Sorenson et al., 1985), some finding lower attrition for the same group (Steer, 1983b), and others finding no difference attributable to race (Ball et al., 1988; McFarlain et al., 1977; Steer,

1983a).

Beutler et al. (1986) reviewed the studies of therapist characteristics and continuation in psychotherapy. They concluded that higher dropout rates and lack of sensitivity to ethnic differences were common in ethnically dissimilar dyads. Furthermore, they cited findings that therapists who exhibit attitudinal flexibility and attunement to ethnic differences have reduced dropout rates and improved outcomes with minorities, even when matched

in ethnically

dissimilar

pairs. Given the importance

of the interaction

between

clients’ ethnicity and therapists’ attitudes, it is not surprising that race is sometimes related to retention, sometimes to attrition, and sometimes uncorrelated with treatment tenure.

Substance Use and Retention The fact that clients who use more drugs have higher attrition rates is true almost by definition and is overwhelmingly confirmed by the evidence. For alcoholics, investigators have found that a history of two or more alcoholism

convictions,

the use of at least one

illicit drug (Leigh et al., 1984), and higher scores on alcoholism screening instruments (Noel et al., 1987) led to a higher dropout rate. Researchers have also found that intoxication upon admission correlated with higher against-medical-advice (AMA) discharges (Beck et al., 1983). Furthermore, dropouts from inpatient alcoholism treatment were apt to be in the advanced stages of alcoholism (Baekeland & Lundwall, 1975). Women with more severe alcohol abuse dropped out of inpatient men who drank more, exhibited

more pathological

alcoholism drinking,

treatment

centers,

as did

and had more symptoms

of

dependence (Beckman & Bardsley, 1986). Drug use has also been shown to be associated with dropout from therapeutic community (Aron & Daily, 1976; Robinson & Little, 1982), outpatient drug-free (Stark & Campbell, 1988; Steer, 1983b), and methadone ner, 1971; Berger & Smith, 1978) treatment.

maintenance

(Babst,

Chambers,

& War-

In contrast to current levels of use, drug-use history is not clearly related to attrition, at least in studies of methadone maintenance (Ball et al., 1988; Szapocznik & Ladner, 1977). Some researchers have even found that clients with shorter use histories have higher dropout rates (Brown et al., 1982/1983; Joe et al., 1982). These sense because drug-use history is confounded with age and may not reflect of the current drug problem; younger age and recent drug history, rather prior opiate use, have been found to correlate with premature termination

results make the intensity than years of from metha-

done treatment (Sorenson et al., 1985). Drug use just prior to and during treatment is a poor prognostic sign due to the concomitant impairments that interfere with clients’ ability to profitably participate in treatment. These problems are exacerbated by iatrogenic factors, because clients’ continued use of drugs causes difficulties between themselves and staff and even other clients. Such experiences hasten clients’ early departure, especially if they are told that treatment is contingent upon cessation of drug use. This response from treatment personnel is understandable and necessary in some cases, but it does not encourage those who con-

Dropping Out

ofSubstance Abuse Treatment

103

tinue to use while in treatment; unfortunately, these are the ones who need help the most. Ongoing substance use must be viewed as quite serious, but clinicians’ responses should enhance,

Crhinafify,

not reduce, the likelihood of continuation

and treatment

completion.

1egai Pressure, and Retention

Pretreatment criminal history has been found to be related to dropping out of methadone (Baekeland & Lundwall, 1975) and alcoholism (Cummings, 1977; Leigh et al., 1984) treatment. On the other hand, number of prior years in prison did not correlate with attrition from methadone treatment in at least one study (Ball et al., 1988). Moreover, Holland (1978) did not find pretreatment criminal history related to retention at Gateway House, perhaps because of the nearly uniform serious criminal

history of narcotic addicts

in therapeutic communities. The fact that pretreatment criminality is related to dropping out is not surprising because many of the crimes committed are caused by intoxication or the illicit behavior required to procure or possess substances. Criminal behavior is thus confounded with severity of substance abuse and would be expected to correlate with attrition on these grounds alone. The effect of current legal pressure

on client retention

(1976)

was related

determined

that legal pressure

is equivocal

to graduating

Aron and Daily

from two therapeutic

communities, although their measure of legal pressure was confounded with drug-use variables. Steer (1983b) employed univariate analysis and found that number of prior felony arrests and involuntary admission were related to length of stay (but not completion of treatment) in drug-free counseling, but this result washed out when these variables were entered into a multiple stepwise regression analysis. Verinis (1986) found no statistically significant relation between legal pressure and retention in VA outpatient alcoholism trearment, possibly due to having only seven subjects in the legal pressure condition, six of which actually did not drop out of during the &month study. Beck et al. (1983) found legal pressure unrelated to AMA terminations in a 2- to 3-week drug and alcohol program, but clients who left AWOL (i.e., those who did not sign a form indicating they were going to leave AMA) were excluded from the sample. Finally, Baekeland

that and

Lundwall reported mixed findings regarding the prognostic value of court mandation on continuation in methadone treatment, as did Harford et al. (1976) in a multimodality addiction treatment facility. Although not directly related to long-term

retention,

court mandation

to treatment

has

a positive effect on attendance during the first,30 days of treatment (McFarlain et al., 1977; Stark & Campbell, 1988). Logically, court mandation improves retention, even in a long-term analysis, because court-mandated clients have the same long-term attrition rates as nonmandated clients and because higher attrition mandated clients due to their heightened drug use.

rates would be predicted

for

Prior Treafmenf History The effects of prior treatment

history are confounded

with age and longevity and severity

of drug use. Older clients have had more opportunity for treatment, and more prior treatment episodes are a logical consequent of a longer and more severe drug history. It is important, however, to consider the data on prior treatment because some clinicians believe that dropouts are “not ready” for change. Implicit in this assertion is that they will be more ready at a later time, perhaps after they have “hit bottom” or suffered enough to be properly motivated. Research results do not confirm clinical lore in that a majority of investigators have found either a positive relation (Beckman & Bardsley, 1986; Brown et al., 198211983; Leigh et al., 1984; Siguel & Spillane, 1978) or no relation (Ball et al.,

104

1988;

M. J. Stark

Feigelman,

1987;

Steer,

1983a,

1983b;

Steer

& Kotzker,

1978;

Szapocznik

&

Ladner, 1977) between prior substance abuse treatment and dropping out of a current treatment episode. These results indicate that clients have as good a chance (or better) of completing their first treatment episode as those that follow, which suggests that clinicians should actively try to prevent attrition early in clients’ treatment

history.

Psychopathology Although psychiatric

diagnosis does not typically correlate with continuation

in outpatient

psychotherapy (Garfield, 1986), specific symptom patterns have sometimes been shown to relate to attrition from substance abuse treatment. A diagnosis of personality disorder was associated with AMA discharges al., 1983; Minnesota

from alcohol and drug inpatient

treatment

(Beck et

Wheeler, Beck, Manderino, Tackett-Nelson, & Gamache, 1984). Elevated Multiphasic Personality Inventory (MMPI) Psychopathic Deviant (Pd) scores

and sociopathic

diagnoses

have been reported

in dropouts

from polydrug

(Keegan

&

Lachar, 1979), alcoholism (Baekeland & Lundwall, 1975; Pekarik, Jones, & Blodgett, 1986), and correctional drug abuse (Robinson & Little, 1982) treatment. Depression has also been found to correlate with dropping out of alcoholism treatment (Linn, 1978; O’Leary et al., 1979), Bardsley, 1986).

although

In spite of these suggestive

one study found this relation findings,

many

investigators

only for men (Beckman

&

cite the ineffectiveness

of

psychometric assessments of pathology in predicting retention. O’Leary et al. (1979) summarized the results of six studies and discerned no differences between alcoholism treatment completers and dropouts using MMPI scores or measures of manifest anxiety, social desirability, structs. Similarly,

ego strength, intelligence, and various other personality tests or conSchroeder, Bowen, and Twemlow (1982) concluded that attempts to

correlate dropping out with measures of personality and psychopathology (including the MMPI, 16PF, Shipley Institute of Living Scale, Kuder, and Holtzman) have produced limited or conflicting results. Craig (1984, 1985) reported that there are few MMPI indices that predict patients

at risk for program

attrition

and that even “good” multiple

regression equations are not cross-validated and do not generalize to independent samples over time. He further noted that studies typically are retrospective in nature, using statistical methods to “predict” dropouts rather than employing prospective on heuristic models. Craig concluded that in a heterogeneous population,

methods based having a diag-

nosis of substance abuse or sociopathy substantially increases the risk of a patient dropping out. Other than that, demographic/biographic or personality measures generally fail to be replicated or vary according to type of program, length of program, substance abused, and are therefore not useful in predicting attrition.

and type of

Studies examining the effects of psychiatric severity have also produced mixed results. Keegan and Lachar (1979) found that, compared to treatment completers, early terminators were characterized by more psychopathology, discomfort, impulsivity, somatic concerns, and alienation. Steer (1983b) determined that overall symptom distress as measured by the Global Severity Index of the SCL-90-R (Derogatis, 1977) was related to treatment duration with drug-free outpatients. However, other researchers have not found SCL-90-R scores to correlate with retention of drug-free outpatients (Stark & Campbell, 1988) or with clients in an alcohol DUI program (Steer, 1983a). One reason for the lack of strong differentiation between substance abuse treatment dropouts and remainers on measures of symptom severity may be a ceiling effect caused by the high level of pathology found in both groups. Investigators have reported that 77 $% of alcoholics (Hesselbrock, Meyer, & Keener, 1985) and about 90 % of drug addicts

(Khantzian & Treece, 1985; Rounsaville, Weissman, Kleber, & Wilber, 1982) have additional lifetime psychiatric diagnoses, with one study reporting an average of 4.8 such diagnoses per substance-abusing client (Ross, Glaser, & Germanson, 1988). Campbell and Stark (1990) found that compared to a normative psychiatric sample, drug abusers had higher scores on eight MCMI scales (Millon Clinical Multiaxial Inventory, Millon, 1977),

while having lower scores on only two (schizotypal,

compulsive).

It also may be,

as is generally the case in community mental health (Craig & Huffine, severely disordered clients, especially those with psychosis or personality addition

to their substance

abuse,

become

system dependent

1976), that disorders in

and are retained

in treat-

ment longer. Cfjeff~ ~ofivafio~ and fx~e~afions Miller (1985) pointed out that clinicians commonly attribute problems in treating alcoholics to their lack of motivation and that ascribing low motivation creates self-fulfilling prophecies

of poor prognosis.

He surmised that stated willingness

or intention

to partici-

pate in treatment is empirically unrelated to actual participation and that other attempts to measure client motivation have likewise shown poor predictive power. Miller indicated that denial,

which is often seen as the key interferant

greater in alcoholics than nonalcoholics, Low motivation example,

is often abstracted

Baekeland

and Lundwall’s

with alcoholics’ motivation,

nor does it predict treatment from inexact conclusion

and poorly defined

that negative

is not

outcome. measures.

or ambivalent

For

attitudes

toward treatment and poor motivation were associated with attrition from outpatient alcoholism treatment was based on global clinical impressions. More recent investigators have determined treatment

that therapists’

assessments of client motivation for substance abuse 1985; Wheeler et al., 1984) but not always related to continu-

were often (Rees,

ation (Verinis, 1986). Indirect measures of motivation

have been used to predict client continuation.

Garfield

(1986) found that one such measure, namely compliance with a requirement of filling out a pretreatment questionnaire, correlated with general psychotherapy treatment tenure. Likewise,

Rees

(1985)

established

that patients

in an alcoholism

treatment

unit were

more prone to complete treatment if they returned a mailed health belief survey. Another indirect measure of client motivation is the source of clients’ referral to treatment; several investigators have reported that self-referred clients remained in treatment those otherwise referred (Baekeland & Lundwail, 1975; Beck et al., 1983;

longer than Noel et al.,

1987). Garfield

(1986)

concluded

that discrepant

expectations

between

therapist

and client

were related to premature termination from psychotherapy. Therapists’ expectations about treatment effectiveness and duration have also been associated with continuation in general psychotherapy,

although

not with complete

consistency

(Beutler

et al., 1986).

Pekarik (1985) and Garfield (1986) both make the excellent point that clients’ expectations of treatment duration are more accurate than those of therapists. Seventy percent of clients expect treatment to last less than 10 sessions (Pekarik, 1985), and the median number of all outpatient visits is actually between five and six (Garfield, 1978), which is clearly Iess than the number of visits expected by therapists (Garfield, 1986). Pekarik and Wierzbicki (1986) observed that it was only clients’ number of expected visits in a stepwise multiple regression that increased the predictability of actual number of sessions attended in a community mental health clinic. They also found that clients expected short-term therapy at a much greater rate than did therapists, with 65% of the therapists preferring treatment to last over 15 sessions, but only 12% of clients expecting therapy to last that long.

106

M. J. Stark

Client confusion or uncertainty about the nature of treatment can be a source of premature termination. Zweben and Li (198 1) d eveloped a scale to measure the disparity between patients’ perceptions about therapy and the expected response as defined by their program staffs responses to a preliminary survey. They found that out of 126 outpatients

in drug-free

treatment,

only 39% of high-discrepancy

patients (scoring above

the sample median) attended four or more treatment sessions, whereas 58.3% of the low-discrepancy patients were retained for at least that long. These results should be viewed with caution because the high-discrepancy patients were less educated and held more blue-collar positions, thereby confounding discrepant expectations with education and occupational

status.

The results of other studies indicate that long-term attenders have attitudes conducive to retention in treatment. Rees (1985) noted that clients retained in alcoholism treatment said they needed more help, regarded return visits as more important, demonstrated more confidence about keeping future visits, regarded their psychiatrist’s advice as more important, and had higher expectations of improvement if they complied with treatment. A lack of clear expectations women,

about treatment

length (Copemann

a belief that one’s health was controlled

dropout (Beckman

& Bardsley,

& Shaw,

1976) and, for

largely by chance also correlated

with

1986).

Therapists and substance-abusing clients disagree as to why clients drop out, and this discrepancy increases attrition. Clients attribute treatment termination to having resolved the problem (e.g., feeling better or no longer using drugs), to financial and other difficulties (e.g., demands of work, child care) that create problems in keeping appointments, or to dislike of the therapy or therapist & Sobell,

1980).

Therapists,

(Craig,

1985; Leigh et al., 1984; Nirenberg,

on the other hand, explain dropout

and treatment

Sobell, failures

as deriving from clients’ negative dispositional characteristics, especially dishonesty, resistance, denial, and lack of treatment readiness (Craig, 1985; Miller, 1985). These explanations greatly differ from clients’ stated reasons for noncompliance, making it difficult for therapists to empathically and productively intervene to prevent dropout. Discrepancies found between substance-abusing clients’ and therapists’ ing of dropout

do not differ dramatically

understand-

from those found in other settings.

Pekarik

and Finney-Owen (1987) found that when dropouts and their therapists in community mental health centers were asked why clients dropped out, they both listed “problem solved or improved” at about the same frequency (30% and 37%) respectively), but “dislike of the therapist or therapy” was reported by more than twice the number of clients than therapists (26% vs. 11%). Therapists estimated their number of visits per client to be an average of 2.5 to 3 times the actual average number, and they also estimated that their own clients dropped out at rates far below the clinic rates. Thus, therapists expected

clients

to remain

in treatment

far longer

than they did; furthermore,

when therapists’ expectations were not met, they underestimated lem and did not recognize dislike of the therapist or treatment

the extent of the probas an explanation for

attrition. One important difference between substance abusers and other clients is that substance abusers’ attributions of “problem solved or improved” within a short treatment episode are less likely to be true than others’ similar attributions. As noted earlier, clients in community mental health who drop out after three or more sessions had improvement rates equal to appropriate terminators (Pekarik, 1985); but for drug abuse treatment, no lasting benefit derives from treatment episodes lasting less than 90 days (Simpson, 1979; Simpson, 1981; Simpson et al., 1979). Although early dropouts may think their problems are solved, the chronic nature of substance abuse with its high relapse rates renders their prognosis as poor as those who receive no treatment.

107

Dropping Out of Substance Abuse Treatment

Several

conclusions

expectations

about client expectations

are more accurate

indicators

and dropout

of the number

are evident.

First,

client

of actual sessions that will be

attended, and this number is considerably smaller than therapists estimate, want, or expect. Next, clients tend to remain in treatment if they see their substance abuse problems as more serious, comply with treatment,

if they have higher expectations of improvement should they and if they are more confident in their ability to comply with

treatment requirements. Third, therapists and clients differ in their understanding of why clients drop out, with clients citing “problem solved or improved” and “dislike of the therapist or treatment”

at a much higher frequency

than therapists,

who tend to explain

dropout by characterizing the client with global negative dispositional attributes such as lack of motivation or treatment unreadiness. Finally, because of the chronic nature of substance abuse, clients err in thinking their problems are solved within a short treatment tenure, and therapists are unlikely to offer fresh and creative approaches to reduce attrition because they do not acknowledge terminating.

the extent of the problem or the clients’ reasons for

TREATMENT Investigators

of alcoholism

treatment

FACTORS

have demonstrated

that the dropout

rate is lower

for inpatient than outpatient programs (Baekeland & Lundwall, 1975), possibly because of shorter inpatient regimens (Schroeder et al., 1982). Moos (1974) reported that inpatient programs with high dropout rates had few social activities and little emphasis on patient involvement, consisted of unfriendly and uncomfortable environments, staff that concentrated on making plans for getting patients out of the hospital.

and had

Baekeland and Lundwall found that for heroin addiction, drug-free treatment had the highest dropout rates, followed by outpatient and inpatient detoxification programs and methadone maintenance. rates should be tempered than detoxification-only of treatment correlates

The fact that drug-free programs have the highest attrition by the understanding that these programs are much longer

treatment regimens, which often last less than 1 month. Length with attrition for substance abusers and general medical patients

(Beckman & Bardsley, 1986; Meichenbaum & Turk, 1987; Wheeler et al., 1984), and shortening detoxification times minimizes dropout during opioid withdrawal (Brewer, Razae,

& Bailey,

1988).

Even though detoxification-only

out rates, they have shorter treatment methadone maintenance, therapeutic

programs

produce lower drop-

tenures and less favorable outcomes than found in community, and outpatient drug-free treatment

modalities (Simpson, 1979; Simpson et al., 1979). Methadone clients are retained the longest (Craig, Rogalski, & Veltri, 1982; Grey, Osborn, & Reznikoff, 1986; Simpson et al., 1979) because of this modality’s extended treatment regimen and because of the opiates prescribed as part of treatment. Stark and Campbell (1991) determined that methadone clients overwhelmingly listed receiving methadone as the most valuable aspect of their treatment rather than individual counseling, group psychoeducational

interventions, and socialization with other clients. Additionally, lower methadone doses were related to dropping out and higher doses to longer retention in several studies (Baekeland & Lundwall, 1975; Szapocznik & Ladner, 1977). However, Brown et al. (1982/1983) found that clinics with flexible dosing policies, which presumedly were responsive to individuals’ circumstances, were the most successful in retaining clients. The importance of responding to individuals’ needs is underscored by Joe et al. (1982), who found that methadone clients were retained longer in smaller clinics with higher staff counseling hours per client and greater per capita expenditures. Clinics without education

108

M. J. Stark

and training had poorer

orientations retention

and with high ratios of noncounseling

rates. The authors

surmised

staff (mainly

medical)

that clients in these clinics were not

getting treatment for the psychological, educational, and vocational problems concomitant to opiate addiction and that attempts to treat a broad range of client problems would lead to better retention. This conclusion is limited by the finding that having more services per se was related to higher dropout, where efforts to do too much without produce a dilution of effort and result. Continuity

suggesting

adequate

a point of diminishing

counseling

of care is one measure of clinics’ responsiveness

staff or economic

to clients, and an important

factor with patients keeping medical appointments (Meichenbaum with alcoholics referred to a treatment clinic after an emergency Blane,

& Hill,

1970).

Fink et al. (1984)

returns support

found that alcoholism

& Turk, 1987) and room visit (Chafetz,

treatment

given by the

unit’s psychiatrist helped to reduce attrition when compared to that given by private psychiatrists, and that clients detoxified in a preferentially designated unit with staff who maintained a strong liaison with staff of the alcoholism unit were retained at a greater rate than those detoxified in the general psychiatric unit. Likewise, Verinis (1986) found that alcoholic outpatient clients had a greater chance of dropping out if they had been referred for detoxification outpatient treatment.

away from the original VA facility where they were to receive

Another measure of clinics’ responsiveness is the rapidity with which prospective clients are seen. Investigators have found that dropping out is reduced by shorter waiting times for initial assessment

or counseling

appointments

(Leigh et al., 1984; Rees et al., 1984).

Clinic convenience, measured by the distance clients must travel to get to treatment, has been related to attrition from general psychotherapy (Fraps, McReynolds, Beck, & Heisler, 1982) and alcoholism treatment (Prue, Keane, Cornell, & Foy, 1979; Verinis, 1986). Given these findings, clinic staff should heed Verinis, who advised that treatment be delivered through many “storefront” operations rather than from a single central source, and Meichenbaum and Turk (1987), who proposed extending care to on-site extensions in the workplace. An apparent exception to the rule that responding to client needs will produce better retention comes from Craig et al. (1982), who examined dropout in a VA inpatient substance

abuse detoxification

unit. They found that clients tended to complete treatment

more if the patient census was higher and if there were increases in therapist and other staff absences during their stay; in other words, the more detoxifying clients were left alone, the less they dropped out. Efforts to relate to staff during detoxification may have been burdensome to clients, suggesting that lack of attention may have been unintentionally responsive to client circumstances and needs at the time. Dropouts from treatment are disproportionately distributed among counselors (Baekeland & Lundwall, 1975; Miller, 1985; Rosenberg, Gerrein, Manohar, & Liftik, 1976). Baekeland and Lundwall describe therapist qualities associated with high attrition as “ ethnocentrism, unconcern for, dislike of, or boredom with the patient. He is also apt to be male, to instruct his charge inadequately . to cancel appointments, to be permissive . introverted and detached” (Baekeland & Lundwall, 1975, p. 768). Rosenberg et al. (1976) found several counselor variables to be related to retention of alcoholics, including being female (over 85% of the clients were male), older and less educated, and demonstrating low levels of extraversion; whereas counselors’ previous history of working with alcoholics, a family history of alcoholism, being a recovering alcoholic, or attitudes about alcoholism did not affect retention. Although this study is merely suggestive due to its small number of subjects (16 counselors), its findings are consistent with Baekeland and Lundwall’s conclusion that attrition can be reduced by

~?o~~in~

initially

satisfying

patients’

OutofSubstance AbuseTreatment

dependency

needs,

alcoholics older, low-key, and nonconfrontive

109

as in this case,

female counselors

offering

male

for their therapists.

through

Gen-

erally, these results are consistent with a macro-analysis of psychotherapy that advocates matching characteristics of the client, the therapist, and the treatment setting to produce the most beneficial outcomes (Orlinsky & Howard, 1986).

ENHANCING Chafetz

et al. (1970)

conducted

RETENTION

a series of experiments

designed

to improve

the show

rate at an alcohol clinic after referral from an emergency service in a general hospital. Their studies showed that immediate and long-term retention could be dramatically improved by (a) welcoming patients and treating them with respect during the initial contact, (b) reducing waiting times and increasing direct patient contact, (c) dealing with concrete patient concerns (e.g., housing, finances), and (d) employing home visits. These interventions caused a manyfold increase in initial and long-term attendance, which is remarkable

given the clients’ multiple negative indicators

and poor prognoses.

Craig (1985) combined use of multiple attrition prevention procedures with a conservation of resources strategy that made entry into a VA drug abuse inpatient treatment unit considerably more difficult for clients who had prior histories of poor attendance and treatment

noncompliance.

Once

admitted,

patients

received

the benefit

of numerous

attrition reduction procedures including (a) using an admissions treatment contract, (b) rearranging staffing patterns so that a counselor was available during evening and weekend hours, (c) establishing frustrations, (d) requiring patients prior to leaving, charge requests.

a “first admission”

group to review rules and deal with client

that all patients who request to leave AMA meet with the other and (e) using a l-day delay before processing any AMA dis-

Craig also instituted

group incentives

and cash bonuses for all inpatient

staff for success in reducing dropout. This two-pronged approach was highly successful, yielding a reduction in AMA terminations from 70% to 20%. Unfortunately, Craig did not report how many of the difficult clients overcame the barriers to inpatient admission, making it impossible to judge the relative efficacy of the exclusionary against the more positive attrition prevention procedures. This also raises the question of whether the outcomes for the entire population originally requesting treatment were improved or hindered by the interventions. Relatively easy and cost-effective procedures to reduce premature termination can be used in the place of more extensive approaches. Decreasing the time between a client’s seeking treatment and the initial appointment has been recommended by Baekeland and Lundwall and has been found to be effective with general medical patients (Meichenbaum & Turk, (Pekarik,

1987; Miyake, Chemtob, & Torigoe, 1985), outpatient 1985), alcoholics (Miller, 1985), drug-free outpatients

psychotherapy clients (Stark, Campbell, &

Brinkerhoff, 1990), and methadone clients (Woody, O’Hare, Mintz, & O’Brien, 1975). Subjects in the Woody et al. study were followed for 5 months; the rapid intake group had higher continuous retention at each month follow-up, and at the end of 5 months the rapid intake group had 55% of its clients remaining while the controls had 30%. The dropout rate was linear and relatively constant for both groups over the study period. Therefore, facilitating the clients’ initial treatment entry yielded higher long-term retention and, by extension, improved outcomes (Ball et al., 1988; Simpson, 1979; Simpson, 1981; Simpson et al., 1979). Other inexpensive interventions have been shown to improve retention. Rogalski (1989) found that meeting with a psychologist within 5 days after admission to a VA substance abuse detoxification unit increased retention. Miller (1985) cited several studies

M. J. Stark

110

in which follow-up phone calls and letters produced better return from referral and better continuation rates with alcoholics in outpatient settings, and Meichenbaum and Turk (1987)

recommended

these procedures

series of three experiments

conducted

to enhance

retention

with outpatient

with medical

alcoholics,

patients.

Nirenberg

In a

et al. (1980)

determined that phone calls and personal letters improved return after missed appointments, but that an impersonal letter had no effect. They found phone calls to be the most cost-effective and efficient mailing costs.

procedure

because

calling

took less staff time and avoided

Baekeland and Lundwall (1975), M elc h en b aum and Turk (1987), and Miller (1985) agree that in order to reduce dropout, patients should be educated about the procedures and aims of treatment. They encourage engaging clients in conversations: (a) to ensure that they understand

and agree to what is expected

of them;

(b) to elicit and discuss

reasons why clients miss appointments, including prior treatment experiences; and (c) to help them to anticipate, develop plans of action, and respond constructively if attendance problems arise. Pretherapy training or role inductions provide this education and have been effective in reducing attrition and improving outcomes with general psychotherapy clients,

especially

1984; Orlinsky

with those from lower socioeconomic

& Howard,

1986; Pekarik,

Most studies of role inductions

1985; Wilson,

groups (Lambert

& Lambert,

1985).

with substance-abusing

clients find that they improve

initial but not long-term retention (Olkin & Lemle, 1984; Panepinto, Galenter, Bender, & Strochlic, 1980; Stark & Kane, 1985), although there have also been some completely negative

results

(Rees,

1986).

Role

inductions

tend to be more

effective

drug-counseling specific (Stark & Kane, 1985) and if clients’ therapy similar to those of their counselors (Panepinto et al., 1980). A number

of additional

tion. Baekeland recommend

suggestions

and Lundwall (1975),

that clinics

if they are

expectations

have been offered to prevent premature Meichenbaum

offer a variety

of treatment

and Turk (1987), modalities

are

termina-

and Miller (1985)

and a wide range

ancillary services and that clients be allowed to negotiate for the most acceptable ment options. These authors also advise using individually customized treatment

of

treatplans

and goals, including attendance requirements, which are established through negotiated discussions. Zweben, Bonner, Chaim, and Santon (1988) advocate allowing clients to postpone threatening treatment decisions (such as setting abstinence as a goal) until they are committed to the treatment process. Finally, Pekarik (1985), in reviewing attrition in community counselors’ counselors’

mental

health,

recommends

the establishment

of attendance

standards

for

performance, the use of educational and supervisory interventions to improve skills, and a quality assurance committee to monitor and solve attendance-

related problems.

CONCLUSIONS Rates for dropping

out of substance

abuse treatment

are very high, but only somewhat

higher than those of clients undergoing a wide range of medical or psychiatric treatments. Presence of social support for the treatment endeavor, availability of resources that can be applied to the cost of treatment, convenience of the clinic’s location, rapidity with which clients are seen, and a host of similar factors affect continuation of substance- and non-substance-abusing clients. This suggests that clinicians may benefit from viewing their substance-abusing clients as having the same fundamental problems with retention as other clients; therefore, they should look beyond substance use for explanations of dropout and ways to improve retention. This does not imply that substance use does not contribute to dropout-clearly it does. But problems caused by drug use exacerbate existing tendencies for treatment nonadherence found universally across clients and treatments.

111

Dropfiing Out of Substance Abuse Treatment

Although dropping

causes for dropout are not particular

out of substance

abuse treatment

to substance

abuse, the consequences

are more severe. Whereas

of

clients in commu-

nity mental health treatment often show improvement even if they drop out after a few sessions, substance abusers do not manifest long-term gain unless they participate in treatment episodes lasting at least several months. It therefore behooves clinicians who treat substance abusers to be especially responsive to the need for client continuation in treatment. One way for clinicians interaction between empowers clinicians sponses (Miller,

to reduce attrition

is to conceive of dropout as resulting from an

clients’ needs and clinics’ offerings. An interactionist perspective by allowing them to influence the probability of desired client re-

1985). Client

attributes

associated

with dropout need not be immutable

hindrances, but they can serve as guides to actions that improve retention. For example, retention differences attributable to gender can be understood in terms of how gender affects the ease, availability, and suitability of treatment options for clients. Similarly, the mixed findings on race and retention

can be conceptualized

as resulting

from varied

client/counselor interactions, some facilitating and others hindering the therapeutic relationship. The effects of social support on retention can be viewed in relation to how this support responds to the treatment absence of social support.

effort rather than as a function of the mere presence or

Different

aspects of clients’ SES also fit well within an interac-

tionist model in that higher income (which makes paying for treatment easier) improves retention, but full-time employment (which may make keeping appointments more difficult) is sometimes

correlated

with attrition.

Even substance

use while in treatment,

which

is highly related to dropout, can be partially understood in the context of clinicians’ response to this problem, thereby opening the possibility for creative and effective interventions. Employing

an interactionist

on the nature

perspective

of their substance

requires clinicians

abuse problems

to be aware of clients’ views

and their perceptions

of the value of

treatment. Unfortunately, counselors underestimate the extent to which their clients drop out and lack knowledge of the reasons clients cite for termination, especially missing “dislike of the therapist or therapy” as a reason for attrition. Client-cited reasons for early termination, such as “problem solved or improved,” are also likely to be in error. The effects of these misunderstandings

could be ameliorated

by clinician-initiated

which all participants express their perspectives on treatment progress, therapeutic relationship, and the utility of treatment continuation.

dialogue in

the quality of the

A plethora of findings should encourage staff to expand their efforts to improve retention More conveniently located, smaller, decentralized clinics, with higher clinical staff ratios and more per capita expenditures, have lower attrition rates. Clients are likely to continue in treatment longer when they receive rapid initial response, individual attention, and continuity of care, and when they are seen in smaller groups in friendly, comfortable

environments.

Inexpensive

personal letters can also be employed extensive and expensive interventions.

techniques

such as reminder

in the absence of resources

telephone

calls and

needed to mount more

The most important factor in preventing attrition is the clinician who is committed to clients’ treatment continuation. Some of the most powerful findings with the most problematic clients (e.g., Chafetz et al., 1970) resulted from the provision of a therapist who immediately attended to the clients’ concerns, making them feel welcome and treating them with interest and respect. Clinicians’ extended effort is needed to rapidly assess clients’ unique situations, to educate them about treatment while remaining open to being informed by them, and, in conjunction with the client, to establish treatment regimens taiiored to each individual and modified as circumstances require. This proactive stance

112

M. J. Stark

will not eliminate premature termination but, when combined with the skillful application of attrition prevention procedures, can significantly reduce dropout and improve client outcome.

author

Acknowledgement-The

for their help in reviewing

wishes to thank Professor

Doran

French

and Dr. Barbara

Campbell

this manuscript.

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November

Accepted

April

9, 1990 22,

1991