Barriers and Facilitators to Treatment Engagement Among Clients in Inpatient Substance Abuse Treatment

Abstract

There is a call for drawing on client voice to provide a rich, nuanced understanding of factors influencing substance treatment engagement as to maximizing treatment benefits. We interviewed 60 clients in a short-term inpatient substance treatment program and examined facilitators and barriers to treatment engagement. Thematic analysis yielded four themes, including perceived treatment needs, trust and counselor rapport, peer inspiration, and organizational factors. Perceived treatment needs serve as both a facilitator and a barrier wherein the acknowledgment of needs led to greater treatment engagement whereas a lack of perceived needs hindered treatment engagement. The establishment of trust and counselor rapport and peer inspiration facilitated treatment engagement. Clients rated several organizational factors including a lack of treatment provision, gender-responsive treatment and infrastructure, and ineffective communication with nonclinical staff as barriers to treatment engagement. Clinical implications include enhancing treatment motivation and counselor rapport, establishing gender-responsive treatment programs, and providing trainings for staff.

Keywords

substance abuse treatment engagement barriers facilitators users’ experiences in health care thematic analysis

Get full access to this article

View all access options for this article.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Angen

M. J.

(2000). Evaluating interpretive inquiry: Reviewing the validity debate and opening the dialogue. Qualitative Health Research, 10, 378–395. doi:10.1177/104973230001000308

Baim-Lance

Tietz

Schlefer

Agins

(2016). Health care user perspectives on constructing, contextualizing, and co-producing “quality of care.” Qualitative Health Research, 26, 252–263. doi:10.1177/1049732315569736

Bloom

Owen

Covington

(2003). Gender-responsive strategies: Research, practice, and guiding principles for women offenders. Retrieved from https://s3-amazonaws-com-443.web.bisu.edu.cn/static.nicic.gov/Library/018017.pdf

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. doi:10.1191/1478088706qp063oa

Brocato

Wagner

E. F.

(2007). Predictors of retention in an alternative-to-prison substance abuse treatment program. Criminal Justice and Behavior, 35, 99–119. doi:10.1177/0093854807309429

Broome

K. M.

Knight

Hiller

M. L.

Simpson

D. D.

(1996). Drug treatment process indicators for probationers and predictors of recidivism. Journal of Substance Abuse Treatment, 13, 487–491.

Broome

K. M.

Simpson

D. D.

Joe

G. W.

(1999). Patient and program attributes related to treatment process indicators in DATOS. Drug and Alcohol Dependence, 57, 127–135. doi:10.1016/S0376-8716(99)00080-0

Cahill

M. A.

Adinoff

Hosig

Muller

Pulliam

(2003). Motivation for treatment preceding and following a substance abuse program. Addictive Behavior, 28, 67–79. doi:10.1016/S0306-4603(01)00217-9

10.

Center for Substance Abuse Treatment. (2005). Groups and substance abuse treatment. In Substance abuse treatment: Group therapy (Treatment Improvement Protocol (TIP) Series, No. 41.). Rockville, MD: Substance Abuse and Mental Health Services Administration (US). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK64223/

11.

Center for Substance Abuse Treatment. (2006). Clinical issues, challenges, and strategies in intensive outpatient treatment. In Substance abuse: Clinical issues in intensive outpatient treatment (Treatment Improvement Protocol (TIP) Series, No. 47.). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK64101/

12.

Chi

F. W.

Weisner

C. M.

(2008). Nine-year psychiatric trajectories and substance use outcomes: An application of the group-based modeling approach. Evaluation Review, 32, 39–58. doi:10.1177/0193841X07307317

13.

De Leon

. (2000). The therapeutic community: Theory, model, and method. New York: Springer.

14.

DiClemente

C. C.

Schlundt

Gemmell

(2004). Readiness and stages of change in addiction treatment. The American Journal on Addictions, 13, 103–119. doi:10.1080/10550490490435777

15.

Drieschner

K. H.

Verschuur

(2010). Treatment engagement as a predictor of premature treatment termination and treatment outcome in a correctional outpatient sample. Criminal Behavior and Mental Health, 20, 86–99. doi:10.1002/cbm.757

16.

Epstein

R. M.

Street

R. L.

(2011). The values and value of patient-centered care. Annals of Family Medicine, 9, 100–103. doi:10.1370/afm.1239

17.

Fiorentine

Nakashima

Anglin

M. D.

(1997). Client engagement in drug treatment. Journal of Substance Abuse Treatment, 17, 199–206. doi:10.1016/S0740-5472(98)00076-2

18.

Flynn

P. M.

Knight

D. K.

Godley

M. D.

Knudsen

H. K.

(2012). Introduction to the special issue on organizational dynamics within substance abuse treatment: A complex human activity system. Journal of Substance Abuse Treatment, 42, 109–115. doi:10.1016/j.jsat.2011.10.029

19.

Ford

J. H.

Green

C. A.

Hoffman

K. A.

Wisdom

J. P.

Riley

K. J.

Bergmann

Molfenter

(2007). Process improvement needs in substance abuse treatment: Admissions walk-through results. Journal of Substance Abuse Treatment, 33, 379–389. doi:10.1016/j.jsat.2007.02.003

20.

Fried

Harris

Eyles

Moshabela

(2015). Acceptable care? Illness constructions, healthworlds, and accessible chronic treatment in South Africa. Qualitative Health Research, 25, 622–635. doi:10.1177/1049732315575315

21.

Garner

B. R.

Hunter

B. D.

Modisette

K. C.

Ihnes

P. C.

Godley

S. H.

(2012). Treatment staff turnover in organizations implementing evidence-based practices: Turnover rates and their associations with client outcomes. Journal of Substance Abuse Treatment, 42, 134–142. doi:10.1016/j.jsat.2011.10.015

22.

Gibbons

C. J.

Nich

Steinberg

Roffman

R. A.

Corvino

Babor

T. F.

Carroll

K. M.

(2010). Treatment process, alliance and outcome in brief versus extended treatments for marijuana dependence. Addiction, 105, 1799–1808. doi:10.1111/j.1360-0443.2010.03047.x

23.

Godlaski

T. M.

Butler

Heron

Debord

Cauvin

(2009). A qualitative exploration of engagement among rural women entering substance user treatment. Substance Use & Misuse, 44, 62–83. doi:10.1080/10826080802525819

24.

Greenfield

S. F.

Brooks

A. J.

Gordon

S. M.

Green

C. A.

Kropp

McHugh

R. K.

. . . Miele

G. M.

(2007). Substance abuse treatment entry, retention and outcome in women: A review of the literature. Drug and Alcohol Dependence, 86, 1–21. doi:10.1016/j.drugalcdep.2006.05.012

25.

Haggis

(2008). “Knowledge must be contextual”: Exploring some possible implications of complexity and dynamic systems theories for educational research. Educational Philosophy and Theory, 40, 159–176. doi:10.1111/j.1469-5812.2007.00403.x

26.

Hartzler

Witkiewitz

Villarroel

Donovan

(2011). Self-efficacy change as a mediator of associations between therapeutic bond and one-year outcomes in treatments for alcohol dependence. Psychology of Addictive Behaviors, 25, 269–278. doi:10.1037/a0022869

27.

Holloway

Todres

(2003). The status of method: Flexibility, consistency and coherence. Qualitative Research, 3, 345–357. doi:10.1177/1468794103033004

28.

Hser

Y.-I.

Polinsky

M. L.

Maglione

Anglin

M. D.

(1999). Matching clients’ needs with drug treatment services. Journal of Substance Abuse Treatment, 16, 299–305.

29.

Hubbard

R. L.

Craddock

S. G.

Flynn

P. M.

Anderson

Etheridge

R. M.

(1997). Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, 11, 261–278. doi:10.1037/0893-164X.11.4.261

30.

Joe

G. W.

Simpson

D. D.

Broome

K. M.

(1999). Retention and patient engagement models for different treatment modalities in DATOS. Drug and Alcohol Dependence, 57, 113–125.

31.

Kalaydjian

Swendsen

Chiu

W. T.

Dierker

Degenhardt

Glantz

Kessler

(2009). Sociodemographic predictors of transitions across stages of alcohol use, disorders, and remission in the National Comorbidity Survey Replication. Comprehensive Psychiatry, 50, 299–306. doi:10.1016/j.comppsych.2008.09.012

32.

Khantzian

E. J.

(1997). The self-medication hypothesis of substance use disorders: A reconsideration and recent applications. Harvard Review of Psychiatry, 4, 231–244. doi:10.3109/10673229709030550

33.

Khantzian

E. J.

Halliday

K. S.

McAuliffe

W. E.

(1990). Addiction and the vulnerable self: Modified dynamic group therapy for substance abusers (The Guilford Substance Abuse Series). New York: Guilford Press.

34.

Klag

S. M.

Creed

O’Callaghan

(2010). Early motivation, well-being, and treatment engagement of chronic substance users undergoing treatment in a therapeutic community setting. Substance Use & Misuse, 45, 1112–1130. doi:10.3109/10826080903499562

35.

Kohn

C. S.

Mertens

J. R.

Weisner

C. M.

(2002). Coping among individuals seeking private chemical dependence treatment: Gender differences and impact on length of stay in treatment. Alcoholism, Clinical & Experimental Research, 26, 1228–1233. doi:10.1016/j.drugalcdep.2006.05.012

36.

Kuerbis

Sacco

(2013). A review of existing treatments for substance abuse among the elderly and recommendations for future directions. Substance Abuse, 7, 13–37. doi:10.4137/SART.S7865

37.

Landrum

Knight

D. K.

Flynn

P. M.

(2012). The impact of organizational stress and burnout on client engagement. Journal of Substance Abuse Treatment, 42, 222–230. doi:10.1016/j.jsat.2011.10.011

38.

Laudet

A. B.

(2007). What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of Substance Abuse Treatment, 33, 243–256. doi:10.1016/j.jsat.2007.04.014

39.

Laudet

A. B.

Stanick

Sands

(2009). What could the program have done differently? A qualitative examination of reasons for leaving outpatient treatment. Journal of Substance Abuse Treatment, 37, 182–190. doi:10.1016/j.jsat.2009.01.001

40.

Laudet

A. B.

White

(2010). What are your priorities right now? Identifying service needs across recovery stages to inform service development. Journal of Substance Abuse Treatment, 38, 51–59. doi:10.1016/j.jsat.2009.06.003

41.

Meier

P. S.

Barrowclough

Donmall

M. C.

(2005). The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the literature. Addiction, 100, 304–316. http://doi.org/10.1111/j.1360-0443.2004.00935.x

42.

Miller

G. A.

(1999). Learning the language of addiction counseling. Boston: Allyn & Bacon.

43.

Morse

J. M.

Barrett

Mayan

Olson

Spiers

(2002). Verification strategies for establishing reliability and validity in qualitative research. International Journal of Qualitative Methods, 1(2), 13–22. doi:10.1177/160940690200100202

44.

National Institute of Alcohol Abuse and Alcoholism. (2007). Alcohol across the lifespan: Five year strategic plan. Retrieved from http://pubs.niaaa.nih.gov/publications/StrategicPlan/NIAAASTRATEGICPLAN.htm

45.

Orford

(2008). Asking the right questions in the right way: The need for a shift in research on psychological treatments for addiction. Addiction, 103, 875–885. doi:10.1111/j.1360-0443.2007.02092.x

46.

Orford

Hodgson

Copello

John

Smith

Black

. . . Slegg

(2006). The clients’ perspective on change during treatment for an alcohol problem: Qualitative analysis of follow-up interviews in the UK Alcohol Treatment Trial. Addiction, 101, 60–68. doi:10.1111/j.1360-0443.2005.01291.x

47.

Orford

Kerr

Copello

Hodgson

Alwyn

Black

. . . Slegg

(2006). Why people enter treatment for alcohol problems: Findings from UK Alcohol Treatment Trial pre-treatment interviews. Journal of Substance Use, 11, 161–176. doi:10.1080/14659890500246540

48.

Palmer

R. S.

Murphy

M. K.

Piselli

Ball

S. A.

(2009). Substance abuse treatment drop-out from client and clinician perspectives. Substance Use & Misuse, 44, 1021–1038. doi:10.1080/10826080802495237

49.

Parkman

T. J.

Lloyd

(2015). Mutual dependence and the “Goldilocks group”: Exploring service user dependency on mutual aid recovery groups. Drugs and Alcohol Today, 15, 49–58. doi:10.1108/DAT-01-2015-0001

50.

Prendergast

M. L.

Greenwell

Farabee

Hser

Y.-I.

(2009). Influence of perceived coercion and motivation on treatment completion and re-arrest among substance-abusing offenders. The Journal of Behavioral Health Services & Research, 36, 159–176. doi:10.1007/s11414-008-9117-3

51.

Prendergast

M. L.

Podus

Chang

Urada

(2002). The effectiveness of drug abuse treatment: A meta-analysis of comparison group studies. Drug and Alcohol Dependence, 67, 53–72.

52.

Prochaska

J. O.

DiClemente

C. C.

Norcross

J. C.

(1992). In search of how people change: Applications to the addictive behaviors. American Psychologist, 47, 1102–1114.

53.

Pulford

Adams

Sheridan

(2011). What do clients want from alcohol and other drug treatment services? A mixed methods examination. Addiction Research & Theory, 19, 224–234. doi:10.3109/16066359.2010.507893

54.

Pullen

Oser

(2014). Barriers to substance abuse treatment in rural and urban communities: A counselor perspective. Substance Use & Misuse, 49, 891–901. doi:10.3109/10826084.2014.891615

55.

Quintero

G. A.

Lilliott

Willging

(2007). Substance abuse treatment provider views of “culture”: Implications for behavioral health care in rural settings. Qualitative Health Research, 17, 1256–1267. doi:10.1177/1049732307307757

56.

Rabinowitz

Marjefsky

(1998). Alcohol & drug abuse: Predictors of being expelled from and dropping out of alcohol treatment. Psychiatric Services, 49, 187–189. doi:10.1176/ps.49.2.187

57.

Scheidlinger

(2000). The group psychotherapy movement at the millennium: Some historical perspectives. International Journal of Group Psychotherapy, 50, 315–339.

58.

Scheidlinger

(2004). Group psychotherapy and related helping groups today: An overview. American Journal of Psychotherapy, 58, 265–280.

59.

Schultz

P. W.

Searleman

(2002). Rigidity of thought and behavior: 100 years of research. Genetic, Social, and General Psychology Monographs, 128, 165–207.

60.

Seay

K. D.

Lachini

A. L.

DeHart

D. D.

Browne

Clone

(2017). Substance abuse treatment engagement among mothers: Perceptions of the parenting role and agency-related motivators and inhibitors. Journal of Family Social Work, 20, 196–212. doi:10.1080/10522158.2017.1300113

61.

Serin

Kennedy

(1997). Treatment readiness and responsivity: Contributions to effective correctional programming. Ottawa: Correctional Service of Canada, Research Branch.

62.

Simpson

D. D.

Joe

G. W.

Brown

B. S.

(1997). Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, 11, 294–307. doi:10.1037/0893-164X.11.4.294

63.

Simpson

D. D.

Joe

G. W.

Rowan-Szal

G. A.

Greener

J. M.

(1997). Drug abuse treatment process components that improve retention. Journal of Substance Abuse Treatment, 14(6), 565–572. https://dx-doi-org.web.bisu.edu.cn/10.1016/j.jsat.2007.02.003

64.

Simpson

D. D.

Rowan-Szal

G. A.

Joe

G. W.

Best

Day

Campbell

(2009). Relating counselor attributes to client engagement in England. Journal of Substance Abuse Treatment, 36, 313–320. doi:10.1016/j.jsat.2008.07.003

65.

Smith

J. A.

Osborn

(2008). Interpretative phenomenological analysis. In Smith

J. A.

(Ed.), Qualitative Psychology (2nd ed., pp. 53–80). London: Sage.

66.

Sofaer

(1999). Qualitative methods: What are they and why use them? Health Services Research, 34(5, Pt. 2), 1101–1118.

67.

Stark

M. J.

(1992). Dropping out of substance abuse treatment: A clinically oriented review. Clinical Psychology Review, 12, 93–116. doi:10.1016/0272-7358(92)90092-M

68.

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2017). Treatment episode data set (TEDS): 2005-2015. National admissions to substance abuse treatment services (BHSIS Series S-91, HHS Publication No. (SMA) 17-5037). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/2015_Treatment_Episode_Data_Set_National/2015_Treatment_Episode_Data_Set_National.html

69.

Urbanoski

K. A.

Kelly

J. F.

Hoeppner

B. B.

Slaymaker

(2012). The role of therapeutic alliance in substance use disorder treatment for young adults. Journal of Substance Abuse Treatment, 43, 344–351. doi:10.1016/j.jsat.2011.12.013

70.

Weisner

Matzger

Kaskutas

L. A.

(2003). How important is treatment? One-year outcomes of treated and untreated alcohol-dependent individuals. Addiction, 98, 901–911. doi:10.1046/j.1360-0443.2003.00438.x

71.

Wickizer

Maynard

Atherly

Frederick

Koepsell

Krupski

Stark

(1994). Completion rates of clients discharged from drug and alcohol treatment programs in Washington State. American Journal of Public Health, 84, 215–221.

72.

Yalom

Leszcz

(2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books.