DoubleTree Hotel
Rockville, Maryland
December 3 & 4, 1996

Lisa S. Onken, Ph.D.
Associate Chief
Treatment Research Branch
Division of Clinical and Services Research

Summary

Meeting Goals:

• Explore recruiting strategies and the process of engagement once clients enter treatment.
• Stimulate new areas of research in understanding treatment readiness.
• Establish relevance to NIDA’s Treatment Initiative, the application of behavior therapy, and the role of Stage II research.

Meeting Process:

Meeting discussions took place among three important and distinct groups of researchers representing motivation research, ethnography, and alternative treatments for hard-to-reach populations. Participants made brief presentations highlighting their research, and a general discussion led by a facilitator followed.

Content:

Motivation to change includes the following important concepts:

• Readiness and stages of change in treatment indicate that substance abusers may be ready to initiate, attend, and comply with treatment, but not to change behavior.
• The psycholinguistics of addiction encompass an analysis of verbal commitments in therapist-client interaction.
• A hierarchy of verbs expresses the degree of client commitment to treatment.
• Analyzing verbal commitments with Motivational Interviewing Techniques can identify patients who are ready to change.
• Motivation for help-seeking is not the same as motivation for change; readiness to change is not the same as readiness for treatment.
• Behavioral economics is a theory of motivation for behavior allocation, including drug use, which provides explanations for behavior choices.
• Treatment readiness is related to client expectations and program goals.
• Avoiding adverse consequences, enhancing self-efficacy, and accepting realistic normative feedback are predictors of positive outcomes.

Ethnographic Investigation: Drug Abusers’ Perspectives on Treatment

• Patients frequently fear and distrust methadone treatment.
• Drug abusers view the crack-using lifestyle as more exciting than the perceived boredom and limited resources of everyday life.
• Rules and regulations of treatment programs need to be modified for low-literacy patients.
• Treatment programs tend to use rule compliance to determine who is "engaged" and who is "resistant."
• Cocaine treatment and 3-day detoxification programs are viewed as ineffective by drug users.
• Roadblocks to treatment include reliance on public transportation that requires a significant commitment of addicts’ time and energy.
• Offering help in "managing" a drug habit and then using incentives for broad behavior change may be constructive steps toward engaging addicts in treatment.
• Addicts use self-management strategies; treatment programs should build on these skills to help addicts in their recovery.
• Social networks are critical to treatment success.

Alternative Approaches to Drug Abuse Treatment

• Case management is a promising intervention for following homeless HIV-positive drug abusers.
• Day treatment that includes transportation and meals helps retain clients.
• Comprehensive services such as abstinence-contingent work therapy and housing enhance treatment.
• Active outreach, reduced waiting time, ancillary services, case management, and motivational interventions increase treatment entry.
• Cost issues need to be explored; case management is costly, but less so than some alternatives.
• Coercion takes forms ranging from criminal justice sanctions to family interventions.

Conclusion:

Convergent findings from motivation research, ethnography, and novel treatments provided valuable treatment readiness information and strategies. Drug treatment may be viewed as a step toward abstinence; however, addicts do not always use treatment in ways consistent with the philosophy of treatment providers. Comprehensive, flexible, multicomponent programs and interdisciplinary research are needed. Dialogue about health services research needs to continue with NIMH, with CSAT, and within NIDA.