Navigation

Drug Addiction Counseling

Research demonstrates that nonpharmacological treatment of drug addiction can be effective, as measured by a reduction in substance misuse, improvements in personal health and social functioning, and reductions in public health and safety risks; however, the specific components associated with effective treatment are not well understood (1-7). It has been consistently documented, however, that the duration of treatment predicts favorable client outcomes (5, 8-10). Less evident is the relationship between the intensity of participation in recovery activities and the cessation of alcohol and drug dependent behavior.

Several studies have determined that frequent attendance at counseling sessions is associated with favorable treatment outcomes (1, 11-15). Increasing the availability of group and individual counseling in outpatient drug treatment programs may increase the frequency of counseling session participation, which in turn enhances overall program effectiveness (11); clients who maintain regular attendance at 12-step programs during and after treatment report higher levels of drug and alcohol abstinence than do those who attend less frequently or not at all (16, 17, 18-22). With respect to duration of treatment, participation in counseling, and attendance at 12-step meetings, existing evidence supports the conclusion that "more is better."

Recent findings from the Drug Abuse Treatment Outcomes Study (DATOS; 23), however, are not always consistent with this conclusion. Examining a subsample of cocaine users, Hser and colleagues (24) determined that frequency of group and individual counseling, assessed during the first month of treatment, did not predict posttreatment abstinence for any modality. Yet, an interaction was found between frequency of individual counseling and treatment history for those participating in outpatient methadone programs; the frequency of individual counseling sessions predicted cocaine abstinence for those with prior treatment histories.

In the same journal issue, Etheridge and colleagues (19) reported that frequency of participation in counseling and in 12-step groups assessed during the third month of outpatient drug-free or long-term residential treatment did not predict level of cocaine use in the year subsequent to treatment. Finding a positive association between level of participation in counseling and in 12-step programs and cocaine use, it was concluded that high levels of counseling and participation in 12-step groups may be "detrimental" (p. 108), although it was noted that the association is not statistically significant.

The purpose of this investigation was to revisit the relationship between participation in recovery activities and the cessation of alcohol- and drug-dependent behavior. Previous research determined that the frequency of group and individual counseling participation predicted posttreatment abstinence, even for those who completed the 6-month outpatient treatment program (1). Another investigation determined that individuals who maintained weekly or more frequent attendance at 12-step meetings during and after treatment reported higher levels of drug and alcohol abstinence than those who attended less frequently or not at all (16, 17).

The current inquiry involved a replication and extension of this research utilizing findings from a new treatment outcome study. The earlier study involved an evaluation of the first 3 years of the Los Angeles Target Cities Treatment Enhancement Project funded by the Center for Substance Abuse Treatment. The current investigation was based on an evaluation of the final 2 years of the project and utilized a different treatment sample (25).

A single question was addressed: Does the frequency and duration of counseling episodes predict posttreatment alcohol and drug abstinence even for those who complete the outpatient program and attend 12-step meetings on at least a weekly basis during and after treatment?

METHOD

The general goal of the Target Cities Project was to improve the accessibility and effectiveness of drug treatment in cities with populations with severe drug problems. A prospective study of clients entering all metropolitan Los Angeles County, California, outpatient drug-free programs was conducted. These programs emphasize abstinence as the recovery goal and maintain an eclectic therapeutic orientation that stresses cognitive-behavioral therapy, 12-step principles, and confrontational activities. Group and individual counseling are the central activities of the programs.

Participants

All 419 adult clients entering any of the 25 Los Angeles metropolitan outpatient substance abuse treatment facilities between July and September 1994 were recruited for study participation. Two clients refused to participate in the study, leaving 417 respondents who completed client intake interviews. Each participant was paid $10.

Eight months after the intake interview, 360 clients were located for a follow-up interview. Of these clients, 1 was in a detention facility that did not permit interviewer access, and 3 clients refused to participate. Interviews were completed for 356 clients (85%). Each participant in the follow-up interview was given $25.

The characteristics of the follow-up sample did not differ from those of the intake sample. About 66% were female, 43% were African-American, 30% were European-American, 23% were Latino, and 4% were either Asian/Pacific Islanders or Native Americans. Client ages ranged from 18 to 55 years, with a mean age of 34.1 years. Average years of education were 11.8. Over half (58%) were married or involved in a committed relationship. About a quarter (26%) of the respondents were employed, and about two-thirds (67%) had been convicted of a crime at some time in their life.

Crack cocaine was the drug most often mentioned as used in the year prior to treatment (56%), followed by marijuana (46%), methamphetamine (24%), cocaine (19%), and heroin (12%). Some 22% of the respondents drank heavily (averaging at least six drinks a day), and 59% were polydrug users. Nearly two-thirds (65%) had at least one previous drug treatment episode.

Although this sample is representative of the population entering treatment at the time of the study, more women were included than in previous time periods. The participating Target Cities programs, as well as most of the comparison outpatient programs, had implemented new services for women, had enhanced existing services, or had specifically targeted women for treatment.

Measures

The UCLA Client-Needs-Services-Outcomes Questionnaire (CNSOQ) was developed by the senior author (1), pretested on a small number of participants in outpatient drug treatment, and modified to increase construct validity and ease of administration. The measurement domains have been described in detail elsewhere (26, 27).

Both primary and moderating variables were examined in the current study. As alcohol and drug use background and treatment history could influence the relationship between counseling intensity and treatment outcome, these variables were included in the analyses as potentially moderating variables.

Primary Variables

To replicate and extend previous research, the primary variables in this investigation included the same measures of participation in outpatient drug treatment programs and regular attendance at 12-step meetings used in previous studies (16, 17).

Recovery Activities

Treatment Completion. The expected duration specified by the participating outpatient treatment programs included in this study is 6 months. All clients are evaluated at the end of this period and assigned a client discharge status by the treatment provider. "Treatment completion" status is assigned to clients who have maintained at least weekly contact with the treatment providers during the 6-month program. About 36% of the sample were assigned a treatment completion discharge status.

12-Step Participation. Previous research indicates that weekly or more frequent participation at 12-step meetings during and after treatment is associated with higher rates of abstinence (16, 17). Approximately 41% of the sample maintained at least weekly attendance at 12-step meetings in the 6 months prior to the follow-up.

Counseling Intensity

Counseling intensity refers to the frequency and duration of counseling episodes, not to the cognitive or emotional character of counseling.

Counseling Session Frequency. Treatment plans typically recommend attending at least three group counseling sessions and one individual counseling session per week. Actual participation among clients, however, varies. Respondent reports of the number of group counseling sessions attended weekly while in treatment ranged from 0 to 5, with a mean of 2.4 and a standard deviation of 1.6. Respondent reports of weekly attendance at individual counseling sessions during the 6-month treatment period ranged from 0 to 5, with a mean of 0.9 and a standard deviation of 1. 1.

Counseling Session Duration. The expected duration of group counseling is typically between 1 and 2 hours, whereas the expected duration of individual counseling is 1 hour. Respondent estimates of the mean number of minutes of group counseling sessions attended, however, ranged from 10 to 240 minutes, with a mean of 73 and a standard deviation of 38. Respondent estimates of the mean number of minutes of individual counseling sessions attended ranged from 10 to 150, with a mean of 42 and a standard deviation of 32.

Treatment Outcome

The goal of this investigation, in conjunction with previous research, was to understand more fully the relationship between participation in treatment and 12-step programs and the cessation of alcohol- and drug-dependent behavior. All measures of this outcome typically used in prospective studies suffer from some limitations. Yet, for those with long histories of drug and alcohol dependence and prior treatment failures (see Moderating Variables), complete abstinence over some, preferably long, time duration may be the most meaningful proxy of recovery than are number of weeks of abstinence or reductions in alcohol or drug use from intake to follow-up. Alcohol and drug dependence are chronic relapsing conditions (28, 29). Using weeks of abstinence often measures time until relapse, with the assumption that an individual with 8 weeks of abstinence prior to a complete relapse has a positive outcome that is twice the value of the outcome of an individual with 4 weeks of abstinence prior to relapse. This assumption may undervalue the fact that both experienced relapse.

Reductions in use from treatment intake to follow-up may assess temporary fluctuations in use rather than sustained recovery. The levels of drug and alcohol use may be inordinately high prior to treatment entry, which may, in fact, have prompted entry into treatment. Reduction in use from intake to follow-up, often interpreted as a favorable treatment outcome, may be simply a return to a more normal level of use, but this level of use could still be problematic and may even meet the criteria for dependency. Finally, there is a growing body of research indicating that sustained controlled use of alcohol and other drugs is unlikely for those whose use has escalated to dependency (30-36). Any measurable reduction in level of use by those dependent on alcohol and other drugs may be only temporary.

Weeks until relapse and reductions in use over time may have only a tangential relationship to cessation of alcohol- and drug-dependent behavior. Complete abstinence seems to assess more accurately the cessation of addictive behavior, although it, too, is far from ideal. Abstinence may be an overly conservative measure of recovery. All abstinent individuals have ceased addictive behavior, at least temporarily, but all who have ultimately ceased their addictive behavior at follow-up may not have been completely abstinent for the entire 6-month assessment period. Still, abstinence seems to assess more accurately the cessation of alcohol- and drug-dependent behavior than other widely used measures. Any days of drug or alcohol use in the 6 months prior to the follow-up are considered nonabstinence. Almost 51% of the sample maintained abstinence over this period.

Moderating Variables

Alcohol Use History. Alcohol use history was operationalized as the number of years of regular alcohol use prior to current treatment entry. Regular use was defined as consumption of one or more alcoholic drinks on at least 3 days per week (range = 0-34, M = 16.4, SD = 18.1). The severity of recent use was measured as the mean number of drinks per week in the year prior to treatment entry (range = 0-175, M = 27.9, SD = 47.0).

Drug Use History. Drug use history was operationalized as the number of years of regular drug use prior to current treatment entry. Regular use was defined as any illicit drug use on an average of 3 days per week (range = 2-41, M = 15.7, SD = 7.9). The severity of recent use was measured by the street market value of daily drug use in the year prior to treatment entry (range = $5-$650, M = $88.6, SD = $118.9).

Treatment History. Treatment history was operationalized as the total number of previous alcohol or drug treatment episodes, excluding detox. The number of previous treatment episodes ranged from 0 to 25, with a mean of 2.3 and a standard deviation of 3.7.

A Note on Self-Report Data

The reliability and validity of self-report data on drug use behavior have been extensively studied. In general, self-report data has been found to be reasonably accurate (37-42). Several studies have empirically examined the reliability and validity of self-reports of alcohol and drug use and have found fairly high to near-perfect rates of agreement between self-reports and urinalysis (43, 44). In addition, accuracy of self-report is improved when confidentiality is guaranteed, as was the case in this study (41, 45-48).

RESULTS

Table 1 presents the results of a hierarchical logistic regression analysis predicting drug and alcohol abstinence. The potentially moderating variables of alcohol use, drug use, and treatment history were entered in step 1, but this did not result in a statistically significant improvement in chi-square values. Entering recovery activity variables, including treatment completion status and weekly or more frequent 12-step participation, in step 2 resulted in a statistically significant improvement in chi square (p < .000) and an increase in predictive accuracy from 57% to 69%.

In step 3, the four measures of counseling intensity were entered individually in four separate equations. Only frequency of group counseling resulted in a statistically significant improvement in chi square (p = .017) and a small increase in predictive accuracy, from 69% to 75%. Entering duration of group counseling episodes and the frequency and duration of individual counseling episodes did not result in statistically significant improvements in chi square nor did they improve the accuracy of predicting abstinence.

Table 2 presents the results of the final step of a logistic regression analysis in which all study variables were entered in the equation in step 1 and sequentially removed from the equation if they met the statistical criterion (p > .05) for removal. The findings indicate that frequency of group counseling remains in the equation, along with years of regular alcohol use, treatment completion, and 12-step participation. The positive coefficient between counseling frequency and abstinence indicates that more frequent participation in group counseling sessions was associated with higher rates of alcohol and drug abstinence even for those who completed outpatient treatment and participated in 12-step programs on a weekly or more frequent basis.

To illustrate the magnitude of the association between group counseling attendance and alcohol and drug abstinence, the logistic regression equation presented in Table 2 was computed with a range of group counseling frequency values. As shown in Table 3, the estimated probability of abstinence for those with 16.4 years of regular alcohol use (sample mean), who complete treatment, maintain weekly or more frequent 12-step attendance, and engage in one group counseling session per week is .77. The probability of abstinence increases to .87 if attendance of group counseling sessions is increased to an average of five times per week. By contrast, the probability of abstinence for those who complete treatment and attend one counseling session per week, but do not maintain weekly participation in 12-step groups is .44. The probability of abstinence increases to .62 if counseling is attended five times per week while in treatment.

DISCUSSION

Replicating and extending earlier findings (1, 11, 16, 17), the results of a prospective investigation of outpatient participants indicate that the frequency of group counseling session attendance predicts higher rates of alcohol and drug abstinence even for those who complete treatment and maintain weekly or more frequent attendance at 12-step meetings during and after treatment. Longer duration of group and individual counseling sessions, however, do not predict higher rates of abstinence, and the modest but statistically significant association between the frequency of individual counseling participation and abstinence found previously (1) was not replicated. Individuals with the highest rates of abstinence (a) completed the 6-month outpatient program, (b) maintained weekly or more frequent attendance at 12-step meetings during and after treatment, and (c) attended five group counseling sessions per week (the most frequent level of attendance) while in treatment.

The findings concerning the frequency of counseling participation are consistent with those of other studies (1, 11, 12-15), but contradict recent findings from DATOS (19, 24). An explanation of these contradictory results is not immediately apparent. In addition to methodological differences, it may be that other aspects of counseling not assessed by these studies, such as counseling availability, are important. Limited counseling availability may restrict the number of episodes attended by the individual. Measures of counseling frequency may not predict outcome when there is little variation in counseling frequency among treatment participants.

It may be, also, that the relationship between counseling frequency and outcomes is dependent on the quality of counseling. Logically, there is no reason to expect that more episodes of ineffectual counseling should improve treatment outcomes. It may be that more is better only when it is better.

Broadening the Research Focus

The general goal of this investigation is consistent with the "second generation" of treatment outcome research. The "first generation" determined that drug treatment can be effective for some individuals (2, 4, 5, 7, 49). The ongoing second generation is attempting to understand the components and characteristics of effective treatment (5, 6, 11, 17, 26, 50-57).

Although the potential contributions from the second generation of treatment outcome research have not been exhausted, more attention to the next generation that examines why treatment and participation in 12-step programs are effective for some individuals may yield important results. Understanding why treatment and participation in 12-step programs are effective suggests the need to identify the psychosocial changes associated with the cessation of addictive behavior and how these changes may be influenced by participation in recovery activities.

An initial foray into this area has determined that completion of outpatient treatment and weekly or more frequent attendance at 12-step meetings during and after treatment may assist in the cessation of alcohol- and drug-dependent behavior, in part, because participation in these activities (a) strengthens the view among participants that moderate or controlled use of alcohol and other drugs is no longer possible, (b) reinforces the perception that the negative consequences associated with continued alcohol and drug use are certain and permanent, and (c) promotes the acceptance of lifelong abstinence as the only likely resolution to current and future problems associated with alcohol and drug use (R. Fiorentine and M. P. Hillhouse, unpublished manuscript, 2000).

The cessation of alcohol- and drug-dependent behavior may require a dramatic cognitive shift in the perceived costs of alcohol and drug use and benefits of lifelong abstinence. Reluctance, if not refusal, to make this cognitive shift may characterize the nature of alcohol and drug dependence. Frequent attendance at group counseling in which the addiction experience is repeatedly discussed may lead to higher rates of abstinence because it promotes the necessary cognitive shift.

A cognitive shift may not be the only answer, but the question is worthy of a concerted research effort. Why does participation in recovery activities, including frequent attendance at group counseling, promote recovery for some individuals?

Table 1. Hierarchical Logistic Regression Analysis Predicting Alcohol
and Drug Abstinence During the 6 Months Prior to Follow-Up (N = 356)

                                                            Predictive
                                     Model Chi-Square       Accuracy
                                       Improvement             (%)

Step 1: Potentially moderating   8.31 (df = 5), p = .140        57
      variables entered
Step 2: Recovery activity        58.74 (df = 2), p < .000       69
      variables entered
Step 3: Counseling intensity
      variables entered
      (in separate equations)
  Group counseling
    Session frequency            5.75 (df = 1), p = .017        75
    Session duration             0.11 (df = 1), p = .744        67
  Individual counseling
    Session frequency            1.21 (df = 1), p = .274        68
Session duration                 1.75 (df = 1), p = .181        68
Table 2. Logistic Regression Analysis Predicting Alcohol and Drug
Abstinence During Six Months Prior to Follow-Up (N = 356)

Variables                            B (SEB)       Wald     p

Moderating variables
  Alcohol use history
    Mean years of regular         0.025 (0.011)     4.78   .029
      alcohol use
    Mean number of alcoholic     Eliminated (a)
      drinks per week consumed
      in year prior to
      treatment entry
  Drug use history
    Mean years of regular          Eliminated
      drug use
    Mean daily dollar amount       Eliminated
      of drugs used in
      year prior to treatment
      entry
  Treatment history
    Number of previous             Eliminated
      treatment episodes
Primary variables
  Recovery activities
    Treatment completion          0.463 (0.126)    13.45   .000
      (yes = 1, no = -1)
    Weekly or more frequent       0.727 (0.122)    35.52   .000
      step 12 participation
      (yes = 1, no = -1)
  Counseling intensity
    Group counseling session      0.175 (0.074)     5.45   .019
      frequency
    (Constant)                   -0.662 (0.325)
    Model chi-square             70.28 (df = 4),
      improvement                  p < .000
    Predictive accuracy          75%

SEB, standard error of B.

(a) Eliminated from equation during backstep removal of statistically
insignificant variables

(p > .05).
Table 3. Estimated Probability of Abstinence by Participation
in Recovery Activities and Frequency of Group Counseling
Sessions (a)

                                       Counseling Session
                                           Frequency

Participation in Recovery Activities    1     3     5

Treatment completion, weekly 12-step
  participation                        .77   .83   .87
Treatment dropout, weekly 12-step
  participation                        .58   .66   .74
Treatment completion, no weekly
  12-step participation                .44   .53   .62
Treatment drop out, no weekly
  12-step participation                .25   .32   .40

(a) Probability estimates from results of the logistic regression
equation presented in Table 2.

ACKNOWLEDGMENT

This research was supported by the National Institute of Drug Abuse (NIDA) Research Scientist Development Award (DA00301); NIDA grants DA11047 and DA11195; and the Los Angeles Target Cities Project, funded by the Center for Substance Abuse Treatment.

REFERENCES

(1.) Fiorentine, R.; Anglin, M.D. More Is Better: Counseling Participation and the Effectiveness of Outpatient Drug Treatment. J. Subst. Abuse Treat. 1996, 13, 341-348.

(2.) Anglin, M.D.; Hser, Y.-I. Drug Abuse Treatment. In Drug and Alcohol Abuse Reviews; Watson, R.R., Ed.; Humana Press: Totowa, NJ, 1992; Vol. 3, 1-36.

(3.) Egertson, J.A.; Fox, D.M.; Leshner, A.I., Eds. Treating Drug Abuse Effectively; Blackwell Publishers of North America: Cambridge, MA, 1997.

(4.) Gerstein, D.R.; Harwood, H.J., Eds. Treating Drug Problems: A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment Systems; National Academy Press: Washington, DC, 1990; Vol. 1.

(5.) Hubbard, R.L.; Marsden, M.E.; Rachal, J.V.; Harwood, H.J.; Cavanaugh, E.R.; Ginzburg, H.M. Drug Abuse Treatment: A National Study of Effectiveness; University of North Carolina Press: Chapel Hill, NC, 1989.

(6.) Kleber, H.D. Treatment of Drug Dependence: What Works. Int. Rev. Psychiatry 1989, 1, 81-100.

(7.) McLellan, A.T.; Woody, G.E.; Metzger, D.; McKay, J.; Durell, J.; Alterman, A.E.; O'Brien, C.P. Evaluating the Effectiveness of Addiction Treatments: Reasonable Expectations, Appropriate Comparisons. In Treating Drug Abuse Effectively; Egertson, J.A., Fox, D.M., Leshner, A.I., Eds.; Blackwell Publishers of North America: Cambridge, MA, 1997; 7-40.

(8.) Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; Ethridge, R.M. Overview of 1-Year Follow-up Outcomes in the Drug Abuse Treatment Outcomes Study (DATOS). Psychol. Addict. Behav. 1997, 11, 261-278.

(9.) Simpson, D.D.; Sells, S.B. Effectiveness of Treatment for Drug Abuse: An Overview of the DARP Research Program. Adv. Alcohol Subst. Abuse 1982, 2, 7-29.

(10.) Simpson, D.D.; Joe, G.W.; Brown, B.S. Treatment Retention and Follow-up Outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychol. Addict. Behav. 1997, 11, 279-293.

(11.) Fiorentine, R.; Anglin, M.D. Does Increasing the Opportunity for Counseling Increase the Effectiveness of Outpatient Drug Treatment? Am. J. Drug Alcohol Abuse 1997, 23, 369-382.

(12.) Crits-Christoph, P.; Siqueland, L.; Blaine, J.; Frank, A.; Luborsky, L.; Omken, L.S.; Muenz, L.R.; Thase, M.E.; Weiss, R.D.; Gastfriend, D.R.; Woody, G.E.; Barber, J.P.; Butler, S.F.; Daley, D.; Salloum, I.; Bishop, S.; Najavits, L.M.; Lis, J.; Mercer, D.; Griffin, M.L.; Moras, K.; Beck, A.T. Psychosocial Treatments for Cocaine Dependence. Arch. Gen. Psychiatry 1999, 56, 493-502.

(13.) Moos, R.H.; King, M.J. Participation in Community Residential Treatment and Substance Abuse Patients' Outcomes at Discharge. J. Subst. Abuse Treat. 1997, 14, 71-80.

(14.) Simpson, D.D.; Joe, G.W.; Rowan-Szal, G.A. Drug Abuse Treatment Retention and Process Effects on Follow-up Outcomes. Drug Alcohol Depend. 1997, 47, 227-235.

(15.) Simpson, D.D.; Joe, G.W.; Rowan-Szal, G.A.; Greener, J.M. Drug Abuse Treatment Process Components that Improve Retention. J. Subst. Abuse Treat. 1997, 14, 565-572.

(16.) Fiorentine, R. After Drug Treatment: Are 12-Step Programs Effective in Maintaining Abstinence? Am. J. Drug Alcohol Abuse 1999, 25, 93-116.

(17.) Fiorentine, R.; Hillhouse, M.P. Drug Treatment and 12-Step Program Participation: The Additive Effects of Integrated Recovery Activities. J. Subst. Abuse Treat. 2000, 18, 65-74.

(18.) Emrick, C.D. Alcoholics Anonymous: Affiliation Processes and Effectiveness as Treatment. Alcohol Clin. Exp. Res. 1987, 11, 416-423.

(19.) Etheridge, R.M.; Craddock, S.G.; Hubbard, R.L.; Rounds-Bryant, J.L. The Relationship of Counseling and SelfHelp Participation to Patient Outcomes in DATOS. Drug Alcohol Depend. 1999, 57, 99-112.

(20.) McKay, J.R.; Alterman, A.I.; McLellan, A.T.; Snider, E.C. Treatment Goals, Continuity of Care, and Outcome in a Day Hospital Substance Abuse Rehabilitation Program. Am. J. Psychiatry 1994, 15, 254-259.

(21.) Montgomery, H.A.; Miller, W.R.; Tonigan, J.S. Does Alcoholics Anonymous Involvement Predict Treatment Outcome? J. Subst. Abuse Treat. 1995, 12, 241-246.

(22.) Watson, C.G.; Hancock, M.; Gearhart, L.P.; Mendez, C.M.; Malovrh, P.; Raden, M.A. Comparative Outcome Study of Frequent, Moderate, Occasional, and Nonattenders of Alcoholics Anonymous. J. Clin. Psychol. 1997, 53, 209-214.

(23.) Simpson, D.D.; Brown, B.S., Eds. Special Issue: Treatment Process and Outcome Studies from DATOS. Drug Alcohol Depend. 1999, 57.

(24.) Hser, Y.-I.; Grella, C.E.; Hsieh, S.C.; Brown, B.S. Prior Treatment Experience Related to Process and Outcomes in DATOS. Drug Alcohol Depend. 1999, 57, 137-150.

(25.) Fiorentine, R.; Gil-Rivas, V.; Hillhouse, M.P. Enhancing Drug Treatment: Evaluation of the Los Angeles Target Cities Project (Years 4-5). Submitted; Center for Substance Abuse Treatment, 1998.

(26.) Fiorentine, R.; Hillhouse, M.P. Drug Treatment Effectiveness and Counselor Empathy: Exploring the Effects of Gender and Ethnic Congruency. J. Drug Issues 1999, 19, 59-74.

(27.) Fiorentine, R.; Nakashima, J.; Anglin, M.D. Client Engagement in Treatment. J. Subst. Abuse Treat. 1999, 17, 199-206.

(28.) Hunt, W.A.; Barnett, L.W.; Branch, L.G. Relapse States in Addiction Programs. J. Clin. Psychol. 1971, 22, 11-17.

(29.) Vaillant, G.E. What Can Long-Term Follow-up Teach Us About Relapse and Prevention of Relapse in Addiction. Br. J. Addict. 1988, 83, 1147-1157.

(30.) Feuerlein, W. Making Explicit What Others Were Assuming. Br. J. Addict. 1987, 82, 844-845.

(31.) Foreyt, J.P. The Addictive Disorders. In Review of Behavior Therapy; Wilson, G.T., Franks, C.M., Kendall, P.C., Foreyt, J.P., Eds.; Guilford: New York, 1987; Vol. 11.

(32.) Foy, D.W.; Nunn, L.B.; Rychtarik, F.G. Broad-Spectrum Behavioral Treatment for Chronic Alcoholics: Effects of Training Controlled Drinking Skill. J. Consult. Clin. Psychol. 1984, 52, 218-230.

(33.) Nathan, P.E. Outcome of Treatment for Alcoholism: Current Data. Ann. Behav. Med. 1986, 8, 40-46.

(34.) Pendery, M.L.; Maltzman, I.M.; West, L.J. Controlled Drinking by Alcoholics? New Findings and a Reevaluation of a Major Affirmative Study. Science 1982, 217, 169-175.

(35.) Rychtarik, R.G.; Foy, D.W.; Scott, T.; Lokey, L.; Prue, D.M. Five- to Six-Year Follow-up of Broad-Spectrum Behavioral Treatment for Alcoholism: Effects of Training Controlled Drinking Skill. J. Consult. Clin. Psychol. 1987, 55, 106-108.

(36.) Sobell, M.B.; Sobell, L.C. Controlled Drinking After 25 Years: How Important Was the Great Debate? Addiction 1995, 90, 1149-1153.

(37.) Ball, J. The Reliability and Validity of Interview Data from 59 Narcotic Drug Addicts. Am. J. Sociol. 1967, 72, 650-654.

(38.) Davidson, R.S.; Stein, S. Reliability of Self-Report of Alcoholics. Behav. Mod. 1983, 6, 107-119.

(39.) Hser, Y.-I.; Anglin, M.D.; Chou, C.-P. Reliability of Retrospective Self-Report by Narcotics Addicts. Psychol. Assess. J. Consult. Clin. Psychol. 1992, 4, 207-213.

(40.) Hubbard, R.; Eckerman, W.; Rachal, J.V. Methods of Validating Self-Reports of Drug Use: A Critical Review. Proc. Am. Stat. Assoc. 1976, 406-409.

(41.) O'Malley, P.M.; Bachman, J.G.; Johnson, L.D. Reliability and Consistency in Self-Reports of Drug Use. Int. J. Addict. 1983, 18, 805-824.

(42.) Stacy, A.W.; Widaman, K.F.; Hays, R.; Dimatteo, M.R. Validity of Self-Reports of Alcohol and Other Drug Use: A Multitrait-Multimethod Assessment. J. Pers. Soc. Psychol. 1985, 49, 219-232.

(43.) Magura, S.; Goldsmith, D.; Casriel, C.; Goldstein, P.J.; Lipton, D.S. The Validity of Methadone Clients' Self-Reported Drug Use. Int. J. Addict. 1987, 22, 727-749.

(44.) Sherman, M.F.; Bigelow, G.E. Validity of Patients' Self-Reported Drug Use as a Function of Treatment Status. Drug Alcohol Depend. 1992, 30, 1-11.

(45.) Babor, T.F.; Stephens, R.S.; Marlatt, G.A. Verbal Report in Clinical Research on Alcoholism: Response Bias and Its Minimization. J. Stud. Alcohol 1987, 48, 410-424.

(46.) Harrison, P.A.; Hoffman, N.G. CATOR Report: Adult Outpatient Treatment Perspective on Admission and Outcome; Ramsey Clinic: St. Paul, MN, 1988.

(47.) Hser, Y.-I.; Maglione, M.; Boyle, K. Validity of Self-Report of Drug Use Among STD Patients, ER Patients, and Arrestees. Am. J. Drug Alcohol Abuse 1999, 25, 81-89.

(48.) O'Farrell, T.J.; Cutter, H.S.; Bayog, R.D.; Dentch, G.; Fortgang, J. Correspondence Between One-Year Retrospective Reports of Pretreatment Drinking by Alcoholics and Their Wives. Behav. Assess. 1984, 6, 263-274.

(49.) McLellan, A.T.; Hagan, T.A.; Levine, M.; Gould, F.; Meyers, K.; Bencivengo, M.; Durell, J. Supplemental Social Services Improve Outcomes in Public Addiction Treatment. Addiction 1998, 93, 1489-1499.

(50.) Berg, W.E. Evaluation of Community-Based Drug Abuse Treatment Programs: A Review of the Research Literature. In The Addiction Process: Effective Social Work Approaches; Freeman, E.M., Ed.; Longman: New York, 1992; 81-95.

(51.) Fiorentine, R. Effective Drug Treatment: Testing the "Distal Needs" Hypothesis. J. Subst. Abuse Treat. 1998, 15, 281-289.

(52.) Fiorentine, R.; Hillhouse, M.P. The Addicted-Self Model of Alcohol and Drug Dependent Behavior Cessation: A Theory of "Natural" Recovery? J. Drug Issues 2001, 31, 395-423.

(53.) Inciardi, J.A.; Tims, F.M.; Fletcher, B.W., Eds. Innovative Approaches in the Treatment of Drug Abuse: Program Models and Strategies; Greenwood Press: Westport, CT, 1993.

(54.) Joe, G.W.; Simpson, D.D.; Sells, S.B. Treatment Process and Relapse to Opioid Use During Methadone Maintenance. Am. J. Drug Alcohol Abuse 1994, 20, 173-197.

(55.) Leukefeld, C.G.; Tims, F.M. Compulsory Treatment for Drug Abuse. Int. J. Addict. 1990, 25, 621-640.

(56.) Simpson, D.D.; Friend, J. Legal Status and Long-Term Outcomes for Addicts in the DARP Follow-up Project. NIDA Res. Monogr. 1988, 86, 81-98.

(57.) Woody, G.E.; McLellan, A.T.; Luborsky, L.; O'Brien, C.P. Psychotherapy and Counseling for Methadone-Maintained Opiate Addicts: Results of Research Studies. NIDA Res. Monogr. 1990, 140, 9-23.

Robert Fiorentine

University of California, Los Angeles, Neuropsychiatric Institute, Department of Psychiatry and Biobehavioral Sciences, Drug Abuse Research Center, 11075 Santa Monica Boulevard, Suite 200, Los Angeles, CA 90025 E-mail: Fiore@ucla.edu

COPYRIGHT 2001 Marcel Dekker, Inc.
COPYRIGHT 2001 Gale Group