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Institute of Behavioral Research, Texas Christian University

Winter 1996-97 Issue

Front Page Stories

IBR: 35 years of treatment research

DATOS research themes reflect new directions

Research Highlights

Also in this Issue

IBR publications in 1996

IBR: 35 years of treatment research

The new year marks IBR's 35th year of conducting social and behavioral research on health and organizational issues and providing training opportunities in graduate and postgraduate education. The Institute was founded by Dr. Saul Sells in 1962 as a separate academic unit at Texas Christian University (affiliated with the Department of Psychology). Under his guidance, the IBR dedicated itself to providing a collaborative and supportive environment for learning and research. When Dr. Sells retired in 1982, Dr. D. Dwayne Simpson, a close colleague and faculty member since 1970, assumed leadership.

Over the years, IBR has played a strong role in the evaluation of national and regional substance abuse treatment programs, including the Drug Abuse Reporting Program (DARP), which followed clients for 12 years after their enrollment in federally-supported treatment programs, and the Drug Abuse Treatment Assessment and Research (DATAR) project, which continues to study treatment enhancements and outcomes in Texas-based methadone maintenance programs. Research interests have expanded in recent years to include substance abuse treatment in criminal justice settings, leading to funding for the Cognitive Enhancements for Treatment of Probationers (CETOP) project, which is currently studying the use of node-link mapping and other visual representation strategies with probationers remanded to residential treatment. Funding also was received for the Prison-Based Treatment Assessment (PTA) project to conduct follow-up evaluations with parolees who were treated in a prison-based therapeutic community established as part of the Texas Criminal Justice Treatment Initiative in 1991.

Early interest in drug treatment evaluation
developed out of the need to satisfy Congress
that treatment works.

35 years allow for perspective

The renewed state and national interest in evaluating criminal justice-based treatment programs comes as no surprise to IBR Associate Director Dr. Lois Chatham, who was invited to reflect on the history of drug abuse treatment evaluation studies in the U.S. for a December meeting of the National Institutes of Health Community Epidemiology Work Group in Austin, Texas. "In putting together my materials," remarked Dr. Chatham, "I was reminded once again that the American public and its legislature are still uncertain whether addiction is a crime or a disease and that this uncertainty influences treatment trends and subsequent treatment evaluation efforts."

She put the national drug abuse treatment evaluation research effort in perspective by identifying a number of events that significantly affected treatment programs in this country. These events included the changing federal position on whether addiction was a crime or a disease, the de-institutionalization movement, public and Congressional skepticism about the value of treatment, and the evolution of management information systems into evaluation efforts.

Dr. Chatham pointed out that the federal civil commitment program begun in 1966, which allowed persons charged with certain drug-related crimes to be committed to treatment instead of being sent to prison, was the first national recognition of a 1962 Supreme Court decision that defined addiction as a disease and not a crime. She attributed the early interest in treatment evaluation as springing from the need of federal program overseers to be responsive to questions raised by a skeptical Congress concerning the value of spending money for the treatment of addiction. The responsiveness of these federal agencies in providing Congress with available data from management information systems was rewarded by the appropriation of additional funds-initially for civil commitment treatment programs, and later for community-based programs to treat clients not legally remanded to treatment. As a matter of historical interest, funding for the first national multi-site evaluation of treatment effectiveness, the DARP project, was in part an effort by NIDA to convince Congress that money allocated for addiction treatment was a worthwhile investment.

National evaluation research efforts over the past three decades
have influenced public policy and contributed
to our understanding of treatment effectiveness.

After pointing out the rationale for federally-funded multi-site, multi-program evaluation studies, Dr. Chatham briefly described some of the most significant findings from major studies conducted over the past three decades -- DARP, TOPS, and DATOS. Because these studies were conducted approximately 10 years apart, they can be used to examine changes in clients and programs over time (see chart below).

Major multisite studies, 1969-present

The DARP (Drug Abuse Reporting Program) study, conducted by IBR, was based on data from 44,000 clients admitted to 52 community-based treatment programs between 1969 and 1972. This study found -- in spite of Congressional and public skepticism -- that treatment of persons addicted to opiates did work, as measured by reductions in crime and drug use, and that treatment could be provided in community-based programs for clients not under civil commitment. It also found that length of time spent in treatment was related to outcomes, that trained lay staff could effectively treat clients, and that methadone maintenance, therapeutic community, and drug free outpatient programs had similar positive outcomes, but that detoxification alone was not associated with good results. DARP developed the methodology that would be used in many future treatment assessment studies and also proved that follow-up studies were feasible.

Ten years later, the Treatment Outcome Prospective Study (TOPS) at Research Triangle Institute (RTI) studied 11,750 clients admitted to 41 treatment programs between 1979 and 1981. Among the important findings of this project were indications that patterns of drug use had changed since DARP, with less daily use of opiates and more use of other drugs. TOPS also found that treatment reduced heroin and cocaine use, that this reduction was maintained for at least two years posttreatment, and that clients with legal involvement stayed in treatment slightly longer indicating that legal involvement did not have a negative impact on outcome as had once been believed. The TOPS data also confirmed that many clients entering treatment had concomitant psychological problems. Finally, cost effectiveness studies showed that for every $1.00 spent on treatment there was a $7.00 savings due to reduced criminal activity. Currently, the Drug Abuse Treatment Outcome Study (DATOS), a cooperative project involving IBR, the National Development and Research Institutes (NDRI), the UCLA Drug Abuse Research Center, and the National Institute on Drug Abuse (NIDA), is looking at 10,010 admissions to 96 programs between 1991 and 1993. Although major studies are still ongoing, some initial findings indicate that the profile of client populations entering treatment continues to change. (See DATOS article, this issue.)

Dr. Chatham summed up her historical overview by commenting on the renewed interest in providing substance abuse treatment for incarcerated and probated offenders, a trend reminiscent of the civil commitment initiative of the 60s. She cautioned the audience that this trend does not mean we are back where we started and that nothing was learned. Rather, it reflects changes in public opinion about how best to interrupt the cycle of drugs and crime along with the willingness of criminal justice officials to see if certain community-based treatment approaches found effective by the research studies discussed above might also work in prisons. She concluded by noting that evaluation research over the past three decades has contributed enormously to our understanding of treatment effectiveness and to major policy decisions at both the state and national levels. She forecast that future studies may well be used to make decisions related to services provided under managed care.

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DATOS research themes reflect new directions

At a November meeting of Drug Abuse Treatment Outcome Study (DATOS) researchers hosted by IBR, details of the treatment research themes chosen for exploration by the cooperative members were outlined. National Development and Research Institutes (NDRI), with Dr. Robert L. Hubbard as principal investigator, will examine issues involved in the selection of treatment by drug users, including client needs, access to services, and support and impediments to treatment selections. In addition, NDRI will look at issues related to the delivery of services and client subtypes. UCLA’s Drug Abuse Research Center (Dr. M. Douglas Anglin, principal investigator) will explore factors in the addiction and treatment careers of drug abusers that influence response to treatment, including the relationship of background variables and drug use histories on decisions to enter treatment. In addition, UCLA researchers will test models of the process of addiction (initiation, progression, cessation and relapse) among treatment clients. The Services Research Branch at NIDA, with Dr. Bennett Fletcher serving as principal investigator, will look at issues significant to policy development including cost-benefit analyses, the changing nature of drug abuse treatment clients and the implications for treatment programming and services, and the relations of client economic conditions to treatment performance. IBR researchers, headed by Drs. Dwayne Simpson and George Joe, will explore issues of client retention and engagement in treatment, including the significance of selected client and program variables on retention and program compliance. Also, factors associated with client motivation for treatment and client perceptions of treatment will be examined to better understand their impact on program retention.

Although each site will focus on separate but complementary themes, all DATOS investigators will make use of four variable domains identified as having particular significance for contemporary drug abuse treatment. These domains include HIV risk behaviors, cocaine use, psychiatric comorbidity, and criminal justice status and activity. Three additional variable domains -- treatment process, retention, and outcome criteria -- have been developed to insure that relevant issues in these important areas are explored and that reports are consistent across sites. In the future, additional waves of studies will be undertaken to look deeper into the research themes and variable domains described.

DARP, TOPS, and DATOS sampled programs
from the same or comparable metropolitan areas nationwide.

Meanwhile, early findings from DATOS highlight the changing nature of client populations and available treatment services in the U.S. Most notably, the findings indicate that clients now entering treatment programs are older. In this initial look at the DATOS data, comparisons were made between the client populations admitted to a sample of methadone maintenance, residential, and outpatient drug free programs using similar data from DARP and TOPS (see chart). Although not a panel study, the large number of programs from the same or comparable metropolitan areas nationwide represented in these three studies helps shed light on changes in treatment populations over time (Table 1 below).

Table 1. Client characteristics over three decades

Not surprisingly, drug use measures indicate that heroin use dropped and cocaine use increased in the years following the DARP study. For example, only a distinct minority of DATOS clients outside methadone maintenance reported frequent heroin use. However, whereas only 16% of all DARP clients reported weekly or more frequent cocaine use, 67% of DATOS residential clients, 42% of methadone clients, and 41% of outpatient clients reported at least weekly use of cocaine. Another troubling issue identified in the DATOS findings so far is the apparent diminution in ancillary treatment services available when clients do enter programs. In looking at changes in ancillary service delivery (e.g., medical, psychological, vocational) from TOPS (1979-1981) to DATOS (1991-1993), the level of services received by clients during the first three months of treatment dropped significantly, with 65% of methadone maintenance clients, 60% of outpatient clients, and 23% of residential clients reporting no ancillary services received.

One-year posttreatment follow-up with DATOS clients has been completed and Year-3 follow-up interviews are slated to begin later this year. The emerging changes in client profiles, drugs of choice, and accessibility to needed services highlight the challenges facing both researchers and drug abuse treatment providers in the years ahead.

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Research Highlights

Dr. George De Leon, a leading scientist in the study of therapeutic communities (TCs) in drug abuse treatment, presented a lecture recently to IBR faculty, students, and invited guests on the background and theoretical focus of the therapeutic community movement. Calling TCs "an orderly social psychological approach to the treatment of addiction," Dr. De Leon discussed some of the challenges involved in the implementation of the TC approach in criminal justice settings. Guests included counselors and supervisors from the Tarrant County Substance Abuse Treatment Facility (SATF), site for IBR’s CETOP Project, the Salvation Army First Choice Program, site of the Women and Children Project, and the Dallas County Judicial Treatment Center at Wilmer, site for several intervention studies currently in development.

Researchers from IBR will present workshops at the upcoming American Methadone Treatment Association (AMTA) national conference to be held in Chicago in April. Dr. Don Dansereau will present on "Using Node-Link Mapping During Treatment," and Norma Bartholomew will lead a workshop on "Straight Ahead: Brief Therapy Approaches for Groups." Also, Eric Schmidt (a former counselor with the DATAR project) and Norma Bartholomew will present "Intimacy and Relationship Skills Groups for Men."

Dr. Joel Bennett, Research Scientist with IBR’s Workplace Project is featured in a recently released American Psychological Association monograph on workplace violence, Violence on the Job: Identifying Risks and Developing Solutions. Dr. Bennett authored a chapter entitled "Alcohol, Antagonism, and Witnessing Violence in the Workplace: Drinking Climates and Social Alienation-Integration."

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IBR publications in 1996

Bartholomew, N. G., & Simpson, D. D. (1996). Time Out! For Men: A training manual from the TCU/DATAR project. Fort Worth: Texas Christian University, Institute of Behavioral Research.

Bennett, J. B., & Lehman, W. E. K. (1996). Alcohol, antagonism, and witnessing violence in the workplace: Drinking climates and social alienation-integration. In G. R. VandenBos & E. Q. Bulatao (Eds.), Violence on the job: Identifying risks and developing solutions. Washington, DC: American Psychological Association.

Bennett, J. B., & Lehman, W. E. K. (1996). Employee attitude crystallization and substance use policy: Test of a classification scheme. Journal of Drug Issues, 26(4), 831-864.

Broome, K. M., Knight, K., Joe, G. W., & Simpson, D. D. (1996). Evaluating the drug-abusing probationer: Clinical interview versus self-administered assessment. Criminal Justice and Behavior, 23(4), 593-606.

Camacho, L. M., Bartholomew, N. G., Joe, G. W., Cloud, M. A., & Simpson, D. D. (1996). Gender, cocaine, and during-treatment HIV risk reduction among injection opiate users in methadone maintenance. Drug and Alcohol Dependence, 41, 1-7.

Camacho, L. M., Brown, B. S., & Simpson, D. D. (1996). Psychological dysfunction and HIV/AIDS risk behavior. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 11, 198-202.

Czuchry, M., & Dansereau, D. F. (1996). Node-link mapping as an alternative to traditional writing assignments in undergraduate psychology. Teaching of Psychology, 23(2), 91-96.

Dansereau, D. F., Joe, G. W., Dees, S. M., & Simpson, D. D. (1996). Ethnicity and the effects of mapping-enhanced drug abuse counseling. Addictive Behaviors, 21(3), 363-376.

Hiller, M. L., Knight, K., Broome, K. M., & Simpson, D. D. (1996). Compulsory community-based substance abuse treatment and the mentally ill criminal offender. The Prison Journal, 76(2), 180-191.

Hiller, M. L., Knight, K., Devereux, J., & Hathcoat, M. (1996). Posttreatment outcomes for substance-abusing probationers mandated to residential treatment. Journal of Psychoactive Drugs, 28(3), 291-296.

Hiller, M. L., Knight, K., & Simpson, D. D. (1996). An assessment of comorbid psychological problems in a residential criminal justice drug treatment program. Psychology of Addictive Behaviors, 10(3), 181-189.

Hiller, M. L., Rowan-Szal, G. A., Bartholomew, N. G., & Simpson, D. D. (1996). Effectiveness of a specialized women's intervention in a residential treatment program. Substance Use and Misuse, 31(6), 771-783.

Peel, J. L., Dansereau, D. F., & Dees, S. M. (1996). Schematic maps: Cognitive tools for enhancing the early stages of counseling. American Journal of Drug and Alcohol Abuse, 22(3), 423-437.

Pitre, U., Dansereau, D. F., & Joe, G. W. (1996). Client education levels and the effectiveness of node-link maps. Journal of Addictive Diseases, 15(3), 27-44.

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http://www.ibr.tcu.edu/pubs/newslet/96-97win.html -- Revised: 6 February 1997
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