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This is to certify that the

dissertation entitled

An Evaluation of a Specialized Dual Disorder Treatment
for Persons with Mental Illness and Substance Use:
Effects of Treatment on Service Use and Outcome

presented by

Bonnie Josephine BootsMiller

has been accepted towards fulfillment
of the requirements for

Ph , D. degree in _Esxcho_logx_

 

    

 

Major professor

Dr. William 5. Davidson, III
Date 2/ 29/ 96

 

MS U is an Affirmative Action/Equal Opportunity Institution 0-12771

 

 

 

 

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DATE DUE DATE DUE DATE DUE

       

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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AN EVALUATION OF A SPECIALIZED DUAL DISORDER TREATMENT
FOR PERSONS WITH MENTAL ILLNESS AND SUBSTANCE USE:
EFFECTS OF TREATMENT ON SERVICE USE AND OUTCOME
By

Bonnie Josephine BootsMiller

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Psychology

1996

ABSTRACT
AN EVALUATION OF A SPECIALIZED DUAL DISORDER TREATMENT
FOR PERSONS WITH MENTAL ILLNESS AND SUBSTANCE USE:
EFFECTS OF TREATMENT ON SERVICE USE AND OUTCOME
By

Bonnie Josephine BootsMiller

Persons labeled dually diagnosed (PLDD) with mental illness and substance use
face daily personal challenges, as well as pose challenges for the service system and
policy makers. Some specialized chemical dependency treatment programs
concurrently address the multiple problems that PLDD have introduced, but seldom has
the effectiveness of these treatments been evaluated. Theoretically based evaluations
are needed to evaluate the effectiveness of these treatments for PLDD.

This study measured the outcomes of a specialized dual disorder unit for PLDD.

A path model investigated length of stay, treatment type, intentions to use AA/NA,
intentions to manage mental health needs, Community Mental Health (CMH) services,
state hospital services, community hospital services, AA/N A, and psychiatric, drug,
alcohol, legal, employment, and residential stability outcomes.

Hierarchical multiple regressions were conducted to evaluate the model.
Results showed that: (1) PLDD who received the dual disorder treatment indicated
intentions to continue treatment beyond discharge than PLDD who received standard
psychiatric treatment, (2) people with intentions to use AA/NA services used more
AA/N A services than those without intentions, (3) people who received dual disorder

treatment did not use significantly more services than those who received standard

psychiatric treatment, (4) use of AA/NA services post discharge related to better
psychiatric functioning at 6 months, and (5) receipt of dual disorder treatment was not
directly related to improved outcomes at 6 months. Other findings seemed to suggest
that people who received more CMH services had more residential instability and
people who received more state and community hospitalizations had worse psychiatric
and employment problems, respectively.

This study revealed the usefulness of theoretical program models when
evaluating treatment programs. Evaluating the treatment process uncovered
relationships between intentions, service use and outcomes. Other effects of multiple
types of services (both formal and informal) on multiple outcomes are important to
consider, because services may have differential impacts on outcomes. Future research
should consider other treatment components such as, motivation to continue treatment
and actual discharge plans, as well as other types of service use (e.g. medieal and dual

disorder) that could influence outcomes.

To my mother Elizabeth Mae (Foote) Boots
a strong woman, good friend, and life confidant.

ACKNOWLEDGMENTS

I would like to thank my family Mom, Dad, Anna Mary, and Tom for all of
their love, support, encouragement, hugs, and prayers throughout my long educational
process. Because of you and your help I have made it to this place in my life. I would
also like to especially thank Mary Grover and the late Elton Grover for their love and
support. Throughout my education I have been blessed by numerous friends and fellow
students Struggling daily with the trials of education. Limited space precludes me from
mentioning you all by name, but please know that you have touched my life and helped
me make it through. The memories we share will live with me forever.

Special thanks goes to Bill Davidson and Sandra Herman for their dedication
and mentoring. I would like to thank the staff on the SAMI Research Project, the
Michigan Department of Mental Health, Northville Regional Psychiatric Hospital, the
Detroit/Wayne Community Mental Health Board, and the National Institute of Mental
Health for funding, supporting, and making this dissertation possible. Thank you God

for helping me through!

ii

TABLE OF CONTENTS

LIST OF TABLES .......................................... v
LIST OF FIGURES ......................................... vi
Chapter 1 ................................................ 1
Introduction .......................................... 1

The Need for Evaluation ............................. 3

Theoretically Based Program Evaluation .............. 4

Purpose ........................................ 7

Description of Literature Search ........................ 8

Theory Driven Models and Mental Health Research ................ 8
Summary ...................................... 15

The Current Model ............................... 16

Dual Disorder Research ................................. 18

Dual Disorder Outcome Research ...................... 19

Summary ................................. 26

Specialized Dual Disorder Treatment, Aftercare, and Outcome. . . 27

Summary ................................. 34

Research Questions .................................... 38
Chapter 2 ............................................... 39
Methods ........................................... 39
Participants .................................... 39

Design ....................................... 43

Dual Disorder Treatment ....................... 44

Standard Treatment .......................... 46

Procedures ..................................... 46

Data Collection .......................... .. . . 46

Measures ...................................... 50

Addiction Severity Index (ASI) ................... 53

Intentions to Use Services ...................... 54

iii

Aftercare Service Use ......................... 54

Results ............................................ 56
Overview of Preliminary Analyses ...................... 56
Regressions of Intention to Use Service Variables ............ 57
Regressions of Service Use Variables .................... 60
Regressions of Outcome Variables ...................... 60
Indirect Paths and Total Effects ....................... 65
Summary ...................................... 65
Chapter 4 ............................................... 69
Discussion .......................................... 69
Evaluation of the Research Questions ............... 70
Support for the Theoretical Model ...................... 73
Extension of Early Work ........................ '. . . . 74
Limitations of the Current Study ....................... 78
Future Research ................................. 79
Conclusions .................................... 81

LIST OF REFERENCES
................................................ 83
APPENDIX A ............................................ 93
Addiction Severity Index Measure ........................... 93
APPENDIX B ........................................... 108
Intentions to Use Services Measure ......................... 108
APPENDD( C ........................................... 109
AA/NA Self Help Measure .............................. 109
APPENDIX D ........................................... 110
Description of cluster solutions ........................ .. . . 110

iv

S9999?!"

LIST OF TABLES

Comparison of Experimental and Control Participants on Study Variables . . . . 42
Comparison of Dual Disorder Treatment and Standard Psychiatric Treatment . . 44
Item-total correlations and coefficient alphas of outcome measures ........ 53
Path Coefficients of the Intentions to Use Services Variables ............ 59
Path Coefficients of the Service Use Variables ..................... 59
Path Coefficients of the Outcome Variables ....................... 63
Direct, Indirect, and Total Effects on Outcome Variables ........... 67 - 68

PP?!"

LIST OF FIGURES

Comprehensive Model .................................... 11
Proposed Model ........................................ 18
Measurement Model ...................................... 52
Significant Pathways ..................................... 64

Chapter 1
Introduction

When the general population is assessed, 20% to 30% are found to have some
type of mental disorder or symptoms of a disorder (Lehtinen, Joukamaa, Lahtela,
Raitasalo, Jyrkinen, Maatela, & Aromaa, 1990). Other studies have indicated that
anywhere from 12% to 15 % of the general population can be diagnosed as having a
mental disorder (Klerman, 1986; Madianos & Stefanis, 1992). Within this population
of persons labeled mentally ill (PLMI), a distinct subset of individuals exists who are
labeled dually disordered (PLDD) with mental illness and substance abuse. Galanter,
Castaneda, and Ferman's (1988) research revealed that over one half of the general
psychiatric population suffered from a substance abuse or substance dependence
problem. Other Studies (Canton, Gralnick, Bender, & Simon, 1989; Drake
& Wallach, 1989; Khalsa, Shaner, Anglin, & Wang, 1991) concurred with this
finding, referring to at least one third of their mentally ill populations as dually
disordered. Although there are several combinations of dual disorders, this dissertation
will focus on those persons who have been identified as having a mental health and a
substance abuse disorder.

This group labeled mentally ill and substance abusers is of great concern to

service providers and policymakers. Individually PLMI and people labeled substance

2

abusers, have difficulty receiving appropriate treatment due to the extent and course of
their problems. Yet, PLDD have even more difficulty because of the multiple effect of
their co-occurring problems. For example, PLDD have had reportedly higher rates of
rehospitalization and higher rates of emergency services usage than PLMI, which
created special treatment issues for their service providers (Bartels, Teague, Drake,
Clark, Bush, & Noordsy, 1993). PLDD have also been at greater risk than PLMI of
suffering from negative effects of substance and alcohol use, such as severe reactions to
drug effects and more difficulty making social adaptations (Brown, Ridgely, Pepper,
Levine, & Ryglewicz, 1989; Moreines, 1991). Because these people pose a greater
challenge to the mental health and substance use service delivery systems, these systems
have had difficulty responding to their special needs. Service system problems include
the following: lack of continuity of care, inadequate assessment and diagnosis, lack of
trained Staff, inadequate array of services, rigid funding streams, lack of
communication and a working relationship between mental health and substance abuse
fields, and limited dissemination of effective program models (Ridgely, Goldman, &
Willenbring, 1990; Thacker & Tremaine, 1989). Policy makers are struggling with
these problems and trying to reduce conflict between service providers, and between
service providers and clients, by combining substance use and mental health treatment
(Ridgely, 1991). A

PLDD also have numerous personal dilemmas that they face on a daily basis.

These people are not only battling the consequences of substance use and severe

3

psychiatric symptomatology (e. g. , they are more likely to have one or more personality
disorders), they are also younger (tending to have these problems throughout their
lives), less able to manage their lives (e.g. , money, meals, activities), more hostile,
more suicidal, less medication compliant, more likely to use multiple drugs, more
likely to have previous hospitalizations, more likely to be unemployed or under-
employed, more likely to be at or below poverty level and to have received external
financial support, more likely to be refused psychiatric care or discharged prematurely,
and more likely to have a dysfunctional relationship with family and psychiatric care-
givers (Brown et al. , 1989; Drake & Wallach, 1989; Fernandez-Pol, Bluestone, &
Mizruchi, 1988; Kanwischer & Hundley, 1990; Ridgely, 1991; Safer, 1987; Schmidt,
1992).
IhefleedIOLEvaluatinn

In light of the service delivery, policy, and personal problems faced by PLDD,
a growing body of literature has indicated the need for specialized treatment for this
population (Brower, Blow, & Beresford, 1989; Drake, Antosca, Noordsy, Bartels, &
Osher, 1991; Minkoff, 1989; Mueser, Bellack & Blanchard, 1992; Osher & Kofoed,
1989; Ridgely, 1991; Sciacca, 1991; Weiss & Mirin, 1989; ). Some of these
treatments have been implemented (Drake, Antosca, et al., 1991; Minkoff, 1989;
Sciacca, 1991). However, studies on treatment outcomes for these specialized
programs are scarce (Blankertz & Cnaan, 1992; Drake, McLaughlin, Pepper, &

Minkoff, 1991; Weiss & Collins, 1992; Weiss & Mirin, 1989). These specialized

4

programs need to be evaluated to determine their effectiveness and to measure the
participants' long term outcomes. Schuster (1991) suggested that mental health
providers begin to encourage funding of studies to evaluate effectiveness of services,
because outcome studies will be critical in preventing further funding limitations on
psychiatric care. Bachrach (1982) noted that improved program evaluations are
necessary to assess the efficacy of community services. Furthermore, Bachrach (1991)
argued that outcome measures are needed, not only to ensure program effectiveness,
but to ensure positive outcomes for consumers. Yet, the service delivery, policy, and
personal problems will not be solved by merely conducting numerous outcome studies,
rather, appropriate theoretically based program evaluations are needed. These
evaluations will identify not only whether the treatment worked, but in what way the
treatment worked.

Ihenrefirallyfiasedfirngramlivaluatinn. It has been strongly suggested that
theoretically based program evaluation provides the best quality evaluations. In
theoretically based program evaluation, evaluators identify the underlying theory for
the treatment program (program theory) and this theory guides the evaluation.
Program theory is both prescriptive and descriptive (Chen, 1989; Chen & Rossi, 1992).
It is prescriptive in that it identifies what program components are needed to bring
about the desired changes in the program participants. This is normative theory.
Normative theory identifies the essential components of the treatment, the kind of

environment in which the treatment is best implemented, and the necessary goals to

5

promote change. Program theory is also descriptive in that it explains the underlying
causal processes of the program. This is causative theory; it identifies what the
intended and unintended impacts are, how the impacts occur, and how the evaluation
results could be generalized. In short, theory driven program evaluations attempt to

describe the problem as well as prescribe a solution.

Bickman (1987) identified 10 ways that using program theory benefits program

evaluation:

(1) ComributingmociaLscienceknmyledge. By providing theoretically
meaningfid independent variables (the program) and dependent variables (the
processes and outcomes), program theory ensures construct validity.

(2) Assistingpolitnrmakem. Understanding the constructs of the program will
allow policymakers to determine if the efi’ects of one program will be beneficial
for other populations, and fimher, to determine ifdtfikrent definitions of the
program theory would produce similar results. The ability to understand the
constructs of one program will help policymakers determine if difi‘erent
operationalizations of the program will work in a similar fashion to the program
that was evaluated.

(3) Dzscnmrnanngbemeenpmgmmfatlureandtheoryfarlure. When designing
an evaluation, researchers need to be able to defend the design, measurement,
and statistical analyses, so that a non-finding can be attributed to the program
and not the theory. If the evaluation is defensible, the program failure is
accurately portrayed.

(4) ldentiézingthepmblemaridJargeLgmup. Program theory should identify
the problem-program match and articulate how the program will impact the
problem. If the appropriate problem is not identified, the program will not
produce positive efi’ects.

(5) erridingpmgmmimplementationdercdption. Program theory describes
the elements and components of the program and their relative importance.
Critical components are identified.

6
(6) WW Using program theory enables evaluators to

disclose effects not considered by program stafl’, either positive or negative.

(7) Specgézingintenreningmriables. Linkages between the program inputs and
outputs are identified and a schematic presentation describes how the variables

are related.

(8) Improyingflzzmatimuseqfiemluation. Program theory can determine
intermediate efl’ects of the program before the program is completed and/or the

fidl efi‘ects are evident.
(9) Claritjzingmeasuzementissues. The use of theory can guide the choice and

development of measures by determining which measure are valid and
appropriate for the program.

(10) Impromngmnsensusfimzatmn. The responsibility of developing program
theon rests with all stakeholders as well as with evaluators. The process of
developing the program theory is informative and educational in itself, which
assists the program stakeholders more than merely identifying program
shortcomings.

These 10 benefits Show how much more knowledge theory driven evaluations provide
when compared to traditional research studies.

Theoretically driven evaluations are needed because they consider inputs (the
treatment) and outputs (outcomes) of programs, and also describe the relationships and
processes that occur between the treatment and the outcome. In general, conducting
evaluations using program theory is an improvement over the traditional ”black box"
evaluations that focus only on inputs and outputs because theory driven evaluations (1)
emphasize the transformational relations between treatment and outcomes, and (2) are
concerned with the contextual factors under which the transformational processes occur

(Chen & Rossi, 1989). Theory driven evaluations of specialized programs for PLDD

7

will not only determine the effectiveness of the treatment, but also reveal how specific
components of the treatment contribute to the effectiveness.
Blame
The purpose of this dissertation is to review the literature on dual diagnosis
treatments and outcomes to:
(1) Show how previous literature has taken a piecemeal approach to evaluating
specialized programs in relation to aftercare service use and outcomes by,
(a) not investigating components of the treatment that may impact
service use,
(b) not evaluating all types of aftercare services, and
(c) not considering all domains in which outcomes could be impacted by
Specialized treatment and aftercare service use;
(2) present a research project that uses a multidimensional, theory based
evaluation of a dual disorder treatment, and specifically,
(a) determines if participation in the dual disorder program leads
participants to use more aftercare services, and
(b) evaluates the relationships between dual disorder treatment and
aftercare service use and psychiatric, drug use, alcohol use,

employment, legal, and residential stability outcomes.

1:"EI' 51

Literature in this review spans the years from 1960 to 1994. A search was
conducted through PsycthEO using the keywords dual diagnosis, outcome, mental
health services, treatment effectiveness, treatment outcome, aftercare, evaluation,
effectiveness, program evaluation, and program theory alone and in combination. The
reference lists of the articles found using these keywords were scanned for additional
articles, books, and other relevant materials. Published articles were included if they
provided information about adult PLDD and their use of services or service use and
outcomes. Articles were excluded from this review if the samples were entirely
adolescents, the elderly, or persons labeled mentally retarded or developmentally
disabled.

ThenqflriuenMndelsandMentalflealtmResearch

Traditionally, psychiatric programs have assessed treatment outcomes with little
regard for the underlying theory of the program. Early studies did not consider how
components of the treatment program lead to the outcomes, rather, they either
compared types of treatments to Show which treatment produced superior outcomes, or
merely assessed outcome (Braun, Kochansky, Shapiro, Greenberg, Gudeman, Johnson,
& Shore, 1981; Friedman, West, & Clark, 1987; Herz, Spitzer, & Endicott, I972;
Hoult, Reynolds, Charbonneau-Powis, Weekes, & Briggs, 1983; Keisler, 1982;
Mosher, 1991; Teesson and Hambridge, 1992) . Furthermore, many of these studies

( 1) suffered methodological flaws such as Short follow-up periods, poor measures of

9

outcome, small samples, (2) measured only one type of outcome, either drug use or
psychiatric, and (3) failed to consider all the important components of the treatment
program.

Aftercare service use is especially lacking investigation in the above studies.
Aftercare is a particularly important component of the treatment process because use of
aftercare can effectually extend treatment, therefore becoming part of the overall
treatment process. It may be misleading to consider only one type of treatment, when
in fact people receive multiple treatment types and all of these treatments can impact
outcomes.

A second treatment component that is important to consider, and that has been
completely ignored in the literature is intention to use services. Intention to use
services is important to the treatment process because it is an indicator of treatment
effect. If a person intends to use services once they leave the hospital, this could be a
Sign that the treatment was a positive experience for them and they want to continue
their progress, or that treatment somehow connected them (either physically or
theoretically) to the appropriate aftercare services. Furthermore, intentions to use
services could impact actual aftercare service use. If persons who have intentions to
use services actually use more services, it would be important to build this component
into the treatment process. The process of treatment cannot be accurately understood

unless all of the treatment components are identified. This knowledge, if applied, will

10

facilitate more effective service combinations being provided to PLMI and PLDD and
encourage the revision or cancellation of ineffective services.

Figure 1 shows a comprehensive model for a theory driven evaluation of a dual
disorder psychiatric treatment program. This model is derived from Finney and Moos'
general conceptual model of evaluation research (1989). This model includes-
admission characteristics of both the participants (individuals) and the treatment.
Individual characteristics are important to establish a baseline record of the participants
as they enter the hospital. It is also important to identify which type of treatment the
person was admitted to, to investigate differences in the type of treatment provided.
Community behaviors and experiences reveal what happened to the participants once
they left the formal treatment setting. This component is important in order to assess if
participants continued with treatment, what type of aftercare treatment was used, and
how their attitudes may have changed once they were outside of the structured hospital
environment. Outcomes measures are necessary in order to evaluate how the process
of treatment and aftercare experience affected the participants and made changes in
their functioning.

As stated above, the research on dual disorder treatments is scarce, thus, many
of the relationships posed in this model (Figure l) have barely been investigated (e.g. ,
the relationship of individual and treatment characteristics to attitudes and beliefs (B &
D), individual and treatment characteristics to services and resources to community

functioning (A -+ F and C -> F), and individual and treatment characteristics to

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attitudes and beliefs to services and resources to community functioning outcomes (B ->
E -r F and D -r E -r F)). Theoretically, these relationships are important to evaluate
service usage and the process of treatment (e.g. , how people maintain treatment and
manage their problems once they leave inpatient treatment). Yet, the literature has
focused on the individual components of this model in isolation.

Studies investigating the predictive effects of mdmdualnharactensncs such as
age, gender, race, socioeconomic status, and education on treatment outcome for PLMI
and substance users are so varied in samples and methods that the results are difficult to
summarize in a meaningful way. Most of these studies considered only a few of the
variables included in Figure 1. For example, Macdonald (1987), in a study of women

alcoholics, found no Significant differences in treatment outcome based on age or

12

marital status. Bachrach (1982) noted that the gender and diagnosis of groups of PLMI
vary greatly depending on the community in which they live. McLellan (1986) has
shown that premorbid functioning is one of the best predictors of outcome for PLDD.
Important information on the impact of prior treatment and family history of substance
use has also been revealed by Kendler, Heath, Neale, and KeSSler (1993).

AS stated earlier, evaluations of treatmenLchamcteristics unique to PLDD are
scarce (Blankertz & Cnaan, 1992; Drake et al., 1993, Drake, McLaughlin, Pepper, &
Minkoff, 1991; Durell, Lechtenberg, Corse, & Frances, 1993; Jerrell & Ridgely,
1995; Weiss & Collins, 1992; Weiss & Mirin, 1989) because the programs are fairly
new and outcomes studies have not yet been conducted. More studies are needed that
evaluate the effectiveness of these services (Schuster, 1991).

Information on sendcesandresources such as state and community
hospitalizations, community mental health services, and self-help for PLDD are also
relatively rare. Narrow, Regier, Rae, Manderscheid, and Locke (1993) found that
most PLDD use mental and addictive disorder specialty settings (e.g. , psychiatric
hospitals, alcohol and/or drug units) (40.5%), as well as their social network consisting
of friends, relatives, and self-help group members (37 %). Alterrnan, McLellan and
Shifman (1993) have shown that substance abusers who have more psychiatric
problems use somewhat more services than abusers who face less psychiatric severity.
The lack of research and treatment effectiveness for PLDD is not surprising due to the

lack of appropriate treatment settings for PLDD. Most services focus on PLMI or

13

substance users in Specific Situations. Services research has also tended to focus on
individual treatment programs (Drake, McLaughlin, et a1. , 1991) rather than the array
of services available in the community (NIMH, 1991). It is important to consider all
available services to determine how the services combine to produce positive outcomes
(NIMH, 1991). ‘

Social networks can also impact outcomes. Crotty and Kulys (1985) have
Shown that for PLMI, social networks tend to be smaller than for the rest of the
population. Although little is known about the social networks for PLDD, this
component is expected to have impact on treatment. Alcoholics Anonymous, for
example, encourages people to change their networks and replace substance using
friends with sober friends. This transition in social support could positively affect
outcomes (Barrera, 1986).

It is generally accepted that economic and financial resources are strongly
negatively related to mental illness, yet Hudson (1988) indicated that there is Confusion
about how this relationship occurs. Traditionally, research has focused on the
relationships between economic resources and functioning (Ensminger & Celentano,
1988; Graetz, 1993; Scott, 1993; Snow, Baker, Anderson, & Martin, 1986; Sosin &
Grossman, 1991), family issues (Franks, 1990; Jones, 1990), and service use (Trainor,
Boydell, & Tibshirani, 1987; Wallen, 1992). Similar discussions have occurred. on the
relationship between economic factors and substance use (Lerner & Raczynski, 1988),

yet little work has been done with PLDD.

14

The substance abuse, medical, and psychology fields have identified and
debated the importance of attitudesandbeliefs with regard to outcomes, treatment
involvement, relapse, and policy. Colon and Massey (1989) unsuccessfully attempted
to change the health attitudes of substance users to alter length of stay in treatment
settings. Faulkner, Sandage, and Maguire (1988) described attitudes toward drinking
and the disease model of alcoholism. Lind (1988) found that attitudes toward drug use
were related to actual use and noted that focusing on the positive aspects of abstinence
is important in order to encourage decreased substance use. Other authors (Alexander,
1987; Brickman, Rabinowitz, Karuza, Coates, Cohn, & Kidder, 1982; Miller & Gold,
1990; Roman, 1988) have discussed the models of chemical use and addiction. Miller
(1985) noted the importance of motivation for change. Furthermore, Ware and Davies
(1983) reported that intentions to use different types of medical services was linked to
satisfaction. Salmon and Quine (1989) investigated participants intentions of what
medical services would entail with regard to their presenting problems. Carney,
Savitz, and Weiskott (1979) evaluated students intentions to use university psychology
counseling services. Intentions to use services iS an important link to investigate. In
order for services such as self-help to be effective people need to change their attitudes
along with their behaviors. Intentions can be seen as a measure of treatment effect and
also as a measure of motivation. Ditrnan, Crawford, Forgy, Moskowitz, and

Macandrew (1967) noted that people who are forced to go to AA/N A do not benefit

15

from that treatment. This would indicate that people need to be motivated to use self-
help and intentions can be viewed as a specific of a type of motivation.

Communityfimctinningmrtcomes include the following variables: medical,
legal, employment/ financial, alcohol, drug, family/ social, psychiatric, residential
stability, living independence, daily activities, symptomatology, and community tenure.
These components cover the areas in which a mental illness and substance use affect a
person's life in the community, as noted by Bachrach (1982), Benda (1987), and
Drake, Antosca, et al. (1991).
Summit

This literature review has described studies that assess some of the variables in
Figure 1. Pieces of the model have been considered, but the collective set of
relationships between admission characteristics, community behaviors and experiences,
and outcomes have not yet been fully considered or explained. Research is needed to
investigate these linkages and evaluate the relationships between the domains.
Specifically, the assessment of multiple outcomes is necessary in order to gain a
comprehensive understanding of the impact of these variables. Investigating only one
or two outcomes ignores effects in other domains and precludes examining the
interrelationships between outcomes. Furthermore, considering the entire treatment
process, provides a better understanding of how outcomes are achieved. The proposed

research will seek to resolve these problems by investigating intentions to use services

16

as a link to multiple types of service use, and evaluate service use in relation to
multiple outcomes.
Ihe_Cnrrent_Model

Due to the size and complexity of the evaluation presented in Figure l,
numerous treatment processes may be evaluated. This dissertation evaluates part of the
outcome process. A model for the current study is provided in Figure 2. This figure is
presented to elucidate the following relationships: (1) Does the specialized treatment
program produce the Short term effects Specified by the model. Namely, does
addressing both mental health and substance use problems concurrently impact
intentions to use services, and do intentions to use services and actual aftercare service
use mediate multiple outcomes for PLDD. (2) DO intentions to use services act as a
linkage to actual aftercare service use and subsequent outcomes or as a measure of
motivation to use services. and (3) Does aftercare service effect important mental
health outcomes. Multiple outcomes and measures of service use were used in this
study to extend the current literature and provide a comprehensive and cohesive
analysis of the treatment process.

This theoretical model is important to investigate because it evaluates how
participants are affected by specialized dual disorder treatment program. By
investigating the mediating effects of the participants' intentions to use community
services after discharge and their aftercare service use, the treatment paths that people

take can be examined. If the specialized dual disorder treatment leads PLDD to have

17

more intentions to use services, it could affect their actual service use and eventual
outcomes. Thus, treatment could be modified to encourage PLDD to start thinking of
aftercare services early in the treatment process. Concomitantly, better linkages could
be encouraged by community based services.

Figure 2 identifies a model that suggests intentions to use services and actual
service use could mediate outcomes of PLDD who have previously received a
specialized dual disorder treatment. In this model, standard psychiatric treatment is
compared to specialized dual disorder treatment. Intentions to use AA/NA and
intentions to manage mental health needs are evaluated as well as, community services,
state hospital services, community hospital services, and AA/NA services. Due to the
prominence of these components in the theoretical literature and the lack of research
evaluating their role as mediators of outcomes, the effects of intentions to use services
and actual service use on multiple outcomes (legal, employment, alcohol use, drug use,
psychiatric functioning, and residential stability) were explored. It was important to
know if these components extend the treatment process and affect outcomes. The
direct impact of dual disorder treatment on intentions to use services, actual service
use, and outcomes were also examined to identify direct effects.

The next section will review dual diagnosis research and Show how it fails to
consider the entire treatment process proposed in Figure 2 when evaluating participant
outcomes. Due to the lack of evaluations of dual disorder treatments, research was

included that evaluates outcomes for PLDD in inpatient specialized, inpatient non-

18

 

Outcomes:
'l‘reotrleltmmterirtia: Employment/6mm
Dual disorder ream Alcohol rue
Standardpsychiatrictreotmeot Dmguse
Psychiatric .

ramming

 

 

 

 

 

     
    
    

Actual Service Use:

    

Intentions to Use

   

 

   

Services: Community services
GotoAA/NA Statemwmiwq
servrces

      

 

 

 

 

Figrle 2.

Proposed Model

Specialized, and community settings for PLDD.

Dual_Disnrder_Research

This section will first review dual diagnosis outcome studies to Show that these

studies have explained parts of the model presented in Figure 2, but have not

considered the entire process of treatment, service use, and outcomes. Most of these

Studies evaluate outcomes without linking them to service use. With the exception of

one study, the articles that do consider service use typically do not consider informal

service use and do not relate service use to psychiatric, drug use, alcohol use, .

employment, legal, and/or residential stability outcomes. Some studies lack

quantitative results. None of the research includes all three critical issues of linking

19

treatment process to outcomes, linking aftercare service use to outcomes, and linking
treatment process to service use.
Dual_Disnrder_Orrtcnme_Research

Case (1991) measured response to treatment. Using a controlled design, 24
PLDD were matched on age, gender, and diagnosis with 24 PLMI. Variables
measured included length of stay, number of suspensions and absences, type of
discharge (planned or unplanned), diagnosis, and number of years of substance abuse.
The dual disorder group had fewer planned discharges (16%) than the mental health
group (54 %). The average length of stay was significantly lower for the dual disorder
group (16 weeks) as compared to the mental health group (25 .5 weeks). Furthermore,
58% of the PLDD left treatment prior to or at eight weeks of treatment. Only 21% of
the PLMI left treatment by that time. Another significant difference was noted in the
percent of unauthorized absences and suspensions per week, with PLDD having 71%
per week and PLMI having only 16% per week. Psychiatric diagnosis and years of
substance abuse were not related to outcome. Case (1991) concluded that psychiatric
day treatment was unsuccessful in treating PLDD.

The outcome measures in Case's study (1991) reflect response to treatment,
rather than Showing actual participant outcome (e.g. , psychiatric functioning, drug
use). As Bachrach (1991) noted, better outcome measures are needed to assess .
participants' progress. Case' s study did not measure post-treatment outcome or

aftercare service use. Outcomes should be assessed in the form of participant

20

functioning so that changes in the participants' functioning can be evaluated rather than
solely behavioral changes (e. g. , did they go to treatment). This study does reveal that
PLDD tend to leave treatment earlier and have more absences than PLMI. Information
such as this reinforces the need for specialized treatment for PLDD. Yet, this study
did not evaluate particular aspects of treatment that could impact outcome or service
use after discharge.

Munsey, Galanter, Lifshutz, and Franco (1992) showed that participants
improve over the course of treatment. This research used a randorrrized design to study
40 persons (randomly selected from 10 inpatient psychiatric wards) diagnosed with
schizophrenia who also abused substances. A psychiatric rating scale and a
questionnaire covering clinical and demographic data were used to evaluate the
participants at adrrrission and discharge. Results Showed that 98 % of the participants
had received prior treatment and that the entire group improved in treatment from
admission to discharge. There were no differences in psychiatric functioning between
occasional drug users (once or twice per week or less) and daily users (one or more
times per day). Daily and occasional drug users differed significantly on impact of
parental substance abuse. AS a group, the participants improved psychiatrically from
admission to discharge.

Munsey et al. (1992) measured psychiatric treatment response from admission
to discharge for PLDD, but no follow-up was conducted to assess long-term outcome

or post treatment service use. Furthermore, no drug use outcome was evaluated and no

21

specific treatment components were evaluated. This study merely shows that all
participants improved over the course of their inpatient treatment. This finding is not
surprising considering that patients enter treatment in a state of crisis and are released
when their functioning has stabilized. This study failed to Show how the treatment
process produced positive outcomes.

Bond, McDonel, Miller, and Pensec (1991) compared formal service use for
persons using an Assertive Community Treatment group (ACT focused on home and
community visits) (N =3 l) or a reference group (R6 focused on group interventions)
(N =23), to a control group (standard community mental health center treatments)

(N =43). All three groups treated PLDD. Interviews and record reviews were
conducted at pretreatment, and at 6 months (N =80), 12 months (N =69), and 18
months (N =75) post discharge. Results showed that at 12 months, 83% of the ROS
and 81% of the ACT participants were Still receiving these services. This result was
Significantly better than the 47% for controls. At 18 months, 83% of the ROS and 65%
of ACT participants were still receiving significantly more services than controls
(40%). Other results suggested that RGS had significantly fewer hospitalizations
(psychiatric, drug use related, and other) than the ACT or control groups at 6 and 12
months. RGs also had significant reductions on alcohol and drug use at 6 and 18
months. However, ACT had significantly fewer days hospitalized at 6 months, and

controls had Significantly fewer days at 18 months.

22

This study is noteworthy because it considered formal service use, though it did
not evaluate this service use in relation to the prior inpatient treatment, nor did it
evaluate psychiatric functioning outcomes or informal service use. However, this study
shows that RGS and ACT are effective in treating PLDD. Both ACT and RGS are
successful in keeping participants involved in services. RGs helped to reduce substance
use and ACT was successful in reducing rehospitalization.

Lyons and McGovern (1989), in a controlled experiment, investigated length of
stay and rate of rehospitalization in a standard state hospital program and aftercare
services at 30, 60, and 90 days post discharge. Of 127 participants, 88 were PLMI and
39 were PLDD. There were no demographic differences between the two groups.
Results showed that PLDD had significantly shorter length of stays during the
admission defined by this research study. However, PLDD had been rehospitalized for
significantly more days than the PLMI by the 90-day follow-up. No differences were
found in the rate of rehospitalization between the two groups. In an attempt to
investigate aftercare linkages, the authors measured attendance at the first scheduled
aftercare session. This measure was insufficient and showed no differences between
the two groups.

This study considered previous standard inpatient treatment, but used a poor
measure of aftercare service use and failed to consider informal aftercare services (e.g. ,
self-help). Rehospitalization was the only outcome measured. This study did reveal

that there were no differences between PLDD and PLMI in attendance at the first

23

formal aftercare session, or in the rate of rehospitalization. PLDD were shown to have
shorter lengths of stay during the index adnrission, but once they were rehospitalized in
the community they were there longer than the PLMI. This study attempted to
consider prior treatment, formal aftercare service use, and outcome, but failed to
consider informal aftercare service use or components of the treatment that may have
impacted service use and outcomes.

A controlled study by Solomon (1986-87) investigated people discharged from
two standard state psychiatric hospital treatments, their receipt of formal aftercare, and
their rate of rehospitalization. Participants (N =497) were categorized into the
following three groups: psychiatric, PLDD, and substance users. Rehospitalization
and aftercare were evaluated for 1 year post discharge.

Results revealed that ouerall a greater proportion of the people in the psychiatric
than in the PLDD group contacted a community mental health agency during the
follow-up. Within the gronp_of_penplereceivingsentices, persons in the substance use
group were more likely than people in the other groups to receive intake, case
management, and emergency services, but less likely to obtain individual treatment.
Further, people receiving services in the PLDD group received more evaluation and
testing, intake, vocational services, day treatment, and emergency services than persons
in the psychiatric group. No differences were found in rate of rehospitalization, but
receipt of services increased community tenure for all three groups. The authors

concluded that community mental health services are geared towards mental health

24

problems rather than substance abuse problems and until more services are tailored to
meet the needs of PLDD, this group oyerall will continue to receive fewer services than
people with solely mental health problems.

Solomon (1986-87) did not evaluate drug and psychiatric outcomes or informal
services, but did shed light on the use of aftercare services. Important findings from
this study include the evidence that PLDD do not receive as many formal services
overall as people with solely psychiatric problems, yet people in the PLDD group were
more likely to receive more of certain types of formal services. This finding could
mean that these people have different needs, that the other services were unnecessary or
inappropriate, or informal services (such as self help) were being used. This study
failed to investigate the use of informal services or aspects of treatment that could have
affected service use.

Finally, Jerrell and Ridgely (1995) compared service use and outcomes of 98
PLDD who were randomly assigned to one of three treatments: behavioral skills
training, case management, or 12-Step recovery. The PLDD involved in this study
were also required to have at least 2 of the following problems beyond their dual
disorder: poor work history, eligibility for and receipt of public assistance, poor basic
living skills, poor maintenance of social support, or history of inappropriate social
behavior that resulted in intervention by mental health or criminal justice authorities.
Interviews were conducted at baseline and 6, 12, 18 and 24 months post entry into the

study and assessed family/ social adjustment, psychosocial functioning, satisfaction with

25
life, interviewer ratings of psychiatric symptoms, residential stability, self-report
ratings of psychiatric and substance abuse symptoms, current alcohol use, and
utilization of mental health treatment and support services (e. g. , emergency services,
skilled nursing, residential treatment, ease management, housing services, and day
services), personal income, work satisfaction, use of medical services, and contact with
criminal justice system. Results in this study reported changes from the 18 month
follow-up data.

The authors found that self-report rates of family/ social adjustment, and
satisfaction with work increased over time. Interviewer ratings of participant
psychosocial functioning were also significant, with increased functioning from 6 to 18
months. Participants showed a significant overall decreases in both observable
psychiatric symptoms and manic, bipolar symptoms, and emergency visits. Significant
overall increases were noted in medication visits, and outpatient visits.

Jerrell and Ridgely (1995) did a good job of evaluating service use and
outcomes, however, service use was treated as an outcome variable and not considered
as a mediator for outcomes. This study also failed to consider treatment components
that could influence service use. Yet, this research revealed that PLDD decreased their
use of acute psychiatric services and shifted their use to outpatient and supportive
services. These results indicate that severe PLDD can be treated in intensive and .

integrated treatments.

26

Snmnraqr. The studies in this section all investigated the outcomes of PLDD
following some kind of treatment. In comparing these studies' findings to‘the proposed
model, it is clear that there are some gaps in the literature. 'leo studies (Case, 1991;
Munsey et al. , 1992) did not consider aftercare service use, or both psychiatric and
substance use outcomes. The other studies provided conflicting results about outcomes
for PLDD. Case (1991) and Lyons and McGovern (1989) showed shorter lengths of
stay for PLDD, whereas, another study (Bond, McDonel, Miller, & Pensec, 1991)
reported that PLDD remained in treatment longer. Solomon (1986—87) suggested that
PLDD do not receive as many formal aftercare services as PLMI, but Lyons and
McGovern (1989) demonstrated that there were no differences between PLDD and
PLMI in attendance of the first formal aftercare session. J errell and Ridgely (1995)
demonstrated that severe PLDD were successful in using less intensive and integrated
treatments.

There were very few articles that investigated outcomes of PLDD. The studies
reviewed above are inadequate at determining how specialized treatment and formal
aftercare service use impact outcomes for the following reasons. First, these articles
only considered treatment of the PLDD in standard programs, rather than evaluating
treatment of PLDD in specialized dual disorder programs. Second, only one of the
above studies (Jerrell & Ridgely, 1995) evaluated the use of informal services (e. g. ,
self-help). It is possible that participants in the other studies were using services

outside of the realm of the formal service network, yet these services were not

27

considered. Third, outcome measures (except Jerrell & Ridgely, 1995) focused on
psychiatric and substance abuse and did not consider other outcomes, such as
employment, legal problems, alcohol use, and residential stability. Fourth, none of the
articles considered specific treatment components in relation to aftereare service use or
outcomes. The investigation of the treatment process was missing completely. These
studies cannot even be considered ”black box" research beeause they fail to consider
the inputs (e. g. , any treatment variables). Rather, they focus on the narrow timeframe
from discharge to follow-up. The next section will review studies of dual disorder
outcomes specifically in Specialized dual disorder treatment settings.

In a non-experimental study of PLDD, Ries and Ellingson (1990) interviewed
20 people at discharge from a Specialized dual disorder program to evaluate service use
and psychiatric and drug outcomes. An interview measured diagnosis, motivation
toward abstinence from substance use, involvement in substance abuse programming
during hospitalization, and discharge plans.

At the 1 month follow-up, 17 participants were contacted and 12 reported
abstinence from substance use. There was a significant difference between abstainers
and non-abstainers in psychiatric diagnosis. Participants who were abstinent were more
likely to be depressed, whereas, those who were non-abstinent were more likely to be
manic. Participants rated their motivation toward abstinence at intake, at discharge,

and at the 1 month follow-up. Persons who were abstainers at 1 month were

28

signifieantly more motivated toward abstinence at all time points. There was no
difference between abstainers and users in psychiatric follow-up care plans, however,
there was a Significant difference between these groups for substance abuse follow-up
care plans. Those who reported abstinence had concrete follow—up plans.

This study focused on motivation towards abstinence from substance use. The
authors used the variables motivation towards abstinence and diagnosis during the
hospitalization to predict abstinence in the community post hospitalization. However,
the study revealed very little about any aftercare service use and nothing about post
treatment outcomes. Although follow-up plans are useful mediators between treatment
and outcome, they are not a realistic measure of outcome because it is not clear that the
participants acted on the plans. Although this study attempted to measure involvement
in treatment, difficulty in measuring this variable precluded the researchers from
further investigation. This study is notable because it began to look at the process from
treatment to outcome. It addressed substance use and psychiatric functioning
outcomes, yet it failed to evaluate outcomes realistically. Furthermore, it evaluated
aftercare plans only in relation to abstinence and not in relation to actual use of
aftercare services.

Pals-Stewart and Schafer (1992) compared the effectiveness of three programs
for treating drug abuse in an outcome study of 60 substance users with obsessive-
compulsive disorders (OCDS). Participants were randomly assigned to either an

integrated 0CD substance abuse treatment, a standard substance abuse treatment, or a

29

progressive muscle relaxation control group. Measures included interviews and a
rating scale measuring length of stay, substance use, OCD preoccupations, diagnosis,
and demographic variables. Participants were evaluated at the beginning of treatment
(N=60) and 1 year later (N=57).

Integrated treatment participants were in treatment significantly longer-than the
other groups, had significantly lower OCD severity scores at discharge and at the 1
year follow-up, and took significantly longer to relapse. Although the substance abuse
treatment group and muscle relaxation treatment group had higher OCD severity
scores, both groups benefitted from significantly reduced OCD severity from discharge
to 1 year follow-up.

This study simply compares the three programs' relative effectiveness at treating
drug abuse. Specific components of the treatment program were not considered in
relation to outcome. Information gleaned from this study does show that participants in
the integrated treatment stayed in treatment longer and took longer to relapse.
Although length of stay was evaluated within the treatment, no aftercare service use
was measured.

Hoffman, DiRito, and McGill (1993) compared chronic PLDD to less severely
impaired (non-chronic) PLDD, all of whom were patients in a specialized psychiatric
substance abuse program, to assess differences in relapse and formal aftercare service
rise. A 3 month follow-up randomized study of 28 PLDD was conducted and

information was gathered from chart reviews, surveys, and phone interviews with

30

primary therapists or probation officers. Outcome measures included abstinence from
substance use, employment, medication compliance, community treatment attendance,
and major untoward events (e.g. , divorce or arrest).

No differences in outcomes were found between the two groups at the 3 month
follow-up. The authors noted that since the non-chronic PLDD were more likely to
have been coerced into treatment by legal pressure, they may have been less motivated,
thus producing similar abstinence rates to those of the chronic PLDD. Moreover,
chronic PLDD may have verbalized their cravings or plans for relapse to primary
therapists or probation officers more than non-chronic PLDD, therefore, explaining the
similarities in outcomes.

This Study is noteworthy in that it found no differences in relapse or formal
aftercare service use between chronic and non-chronic PLDD. However, it did not
consider the use of informal aftercare services in relation to outcomes, or prior
treatrrrent components in relation to aftercare service use or outcomes. It also contains
some critical flaws. First, participants were not interviewed. All information was
gained through therapists or probation officers who did not have continuous contact
with these people. Second, a Single brief follow-up period was used and no psychiatric
outcome was measured. Third, formal aftercare service use was measured by only one
item and the type of services attended were not specified. Fourth, the study evaluated
the outcomes from discharge to 3 months post-discharge; the relational process from

treatment to outcomes was not considered at all.

31

Alfs and McClellan (1992) used a non—randomized design to compare 98
persons attending an integrated day hospital program for PLDD with community
mental health aftercare and 129 persons attending a dual disorder program and a weekly
aftercare group. The programs were primarily group treatment with an open-ended
format. The goals of the dual disorder program were to reduce the number of
hospitalizations, improve medication compliance, and reduce substance use in the dual
disorder program.

Program completion rates were lower in the dual disorder treatment (66%) than
the standard treatment (77 %). Only 97 participants, 34 in the weekly aftercare group
and 63 in the community mental health aftercare treatment were followed. From a
review of the case studies, the authors concluded that little difference in treatrnent
outcome was found due to program type. The more important factor influencing
outcome was ability to function in a group. This study is merely a comparison of the
two program types. N 0 information about treatment components was evaluated. It is
hindered considerably by the lack of quantitative data (e.g. , no quantitative information
about aftercare service use was reported).

A non-randomized study of PLDD (Clopton, Weddige, Contreras, Fliszar, &
Arredondo, 1993) evaluated an integrated chemical dependency inpatient treatment
which discharged people to a 4 month formal aftercare program. The following three
groups of PLDD were considered: (a) those with a personality disorder (n =18), (b)

those with traits of a personality disorder (11 =24), and (c) those with another

32

psychiatric disorder (n =49). Seven clients were discharged Shortly afler starting the
aftercare program and 20 clients did not start the program. The remaining 64 clients
completed the aftercare program, attending for five sessions or more. Outcome
measures included whether the participants completed the aftercare program and
whether they remained abstinent from drugs. .

There were no significant differences between the three groups regarding
abstinence. Overall, 59% remained abstinent. There were also no significant
differences between the groups in the number of people who both completed the
aftercare program and remained abstinent. However, those who abstained were
Significantly more likely to complete aftercare and those who relapsed were more likely
to drop out.

This study also suffers from a lack of quantitative results. Aftercare service use
was only briefly mentioned in relation to the clients' use of one formal aftercare
program. The only data reported was that 64 clients attended for five or more sessions.
No information on service use was provided by type of client (e.g. , which group they
were in). Furthermore, the use of other formal community services or informal
services other than the aftercare program were not measured. Psychiatric outcome was
also not considered. This article fails to address the effect of treatment components on
service use or outcomes. However, it does Show that substance use affects service use.

A non-experimental 4-year follow-up study was carried out by Drake,

McHugo, and Noordsy (1993) to evaluate substance use outcomes of PLDD. Eighteen

33

persons labeled schizophrenic and alcoholic were treated in a specialized dual diagnosis
program. Alcohol and drug use were assessed through interviews, clinicians' ratings,
clinieal records, and intensive case reviews. Remission was defined as no use for 6
months. Attrition at 4 years was not reported. All participants were engaged in ACT
treatment, community mental health center services, and housing supports, and were on
antipsychotic medication throughout the 4-year follow-up period. F urtherrnore, 13
participants attended community dual diagnosis groups, 1 attended self-help groups,
and 1 completed an inpatient substance abuse program. Unfortunately, the persons
completing the latter two treatments did not attain remission.

Results Showed that 61% were in remission at the time of the 4 year follow-up.
The authors noted that these findings are in marked contrast to poor Short term
outcomes of PLDD, and enhance rates of stable remission found in long-term studies of
alcohol treatment. They also theorized that substance abuse treatment contributed to
remission by offering consistent and longitudinal treatment.

Drake et a1. (1993), although failing to measure psychiatric outcome,
considered substance use outcome in relation to service use. Both formal and informal
service use was evaluated. The authors noted that consistent, longitudinal aftercare
treatment following specialized dual disorder treatment could have affected substance
outcome, yet they failed to test this hypothesis or specify what kind of aftercare

treatment might be most beneficial.

34

Summary. In contrast to the first section that reviewed dual diagnosis outcome
studies following various kinds of treatment, this section presented studies that
evaluated specialized dual diagnosis treatments and attempted to consider aftercare
service use in relation to the dual treatments and outcomes.

The research in this section provides the following useful information: (a) two
studies found no differences in rates of abstinence or completion of aftercare between
different categories of PLDD, (Clopton et al., 1993; Hoffman et al., 1993), (b) one
study found that PLDD stayed in treatment longer and took longer to relapse (Fals-
Stewart & Schafer, 1992), (c) one study concluded that remission was stimulated by
consistent and longitudinal aftercare (Drake et al. 1993), and (d) PLDD who abstained
from drug use were more likely to complete aftercare and PLDD who relapsed were
more likely to drop out of aftercare (Ries & Ellingson, 1990; Clopton et al., 1993).
Yet, the research still suffered the following flaws in comparison to the current model
presented above: lack of quantitative results or poor measures (Alfs & McClellan,
1992; Clopton et al., 1993; Drake et al., 1993; Hoffman etal., 1993), no information
on psychiatric, legal, or residential stability outcomes (Ries & Ellingson, 1990; Fals-
Stewart & Schafer, 1992; Drake et al. , 1993), and no investigation into components of
the treatment program and how they affect outcomes or service use (Alfs & McLellan,
1992; Drake et al., 1993; Pals-Stewart & Schafer, 1992; Hoffman et al., 1993; Ries. &

Ellingson, 1990).

35

None of the studies presented in the two sections above evaluated the entire
process of treatment shown in Figure 2, rather they explained individual pieces of the
model. Several Studies (Clopton et al., 1993; Drake et al., 1993; Hoffman et al.,
Jerrell & Ridgely, 1995; 1993; Lyons & McGovern, 1989; Solomon, 1986-87)
attempted to evaluate the pathway D —> C indicated in Figure 2, however, three of these
studies used severely limited measures of formal service use (Clopton et al. , 1993;
Hoffman et al. , 1993; Lyons & McGovern, 1989) two measured only a single outcome
variable (Drake et al., 1993; Solomon, 1986-87). Only one study (Drake et al., 1993 )
tried to investigate informal service use (e.g. , self-help). Four studies merely
evaluated pathway E, the link from treatment to outcomes (Alfs & McLellan, 1992;
Case, 1991; Fals-Stewart & Schafer, 1992; Munsey et al., 1992; Ries & Ellingson,
1990). Finally, only one study (Bond et al. , 1991) evaluated pathway C from service
use to outcomes. The literature clearly does not consider any component of the
treatment (e. g. , intentions to use services) that may mediate the effect of service use on
outcomes. This relationship (A —> B -r C in the current model) is theoretically
important because it may reflect treatment involvement, treatment effectiveness or
motivation to continue with treatment. Intention to use services may be a first step in
getting participants to continue their recovery after hospitalization. Furthermore,
outcomes in terms of psychiatric functioning, legal problems, and residential Stability,

and aftercare service use from multiple agencies (including formal and informal

36

agencies) was considered only once (J errell & Ridgely, 1995) and this study did not
relate the service use and outcome dimensions.

Many of the studies cited above were not concerned with evaluating the process
of treatment, because they do not consider the treatment itself or treatment and service
use components that may mediate outcomes. Theoretical evaluations are needed to
investigate these relationships. This information will help give purpose and meaning to
the evaluation of outcomes, and further give an accurate description of the treatment
process. AS Bickman (1987) stated, theoretical evaluations are needed to provide more
knowledge to the field of dual disorder treatment and to reveal what specific treatment
components mediate particular outcomes. This information will begin to explain how
the treatment process works for PLDD and under what conditions.

Aftercare service use, both formal and informal, is an important component of
this model because these services extend treatment and become part of the treatment
process. Inpatient treatment and aftercare services are not separate entities, but
components of the overall treatment process. The whole process of inpatient treatment
and formal and informal aftercare services needs to be evaluated in order to determine
how the components interact to mediate/impact outcomes. This research cannot be
done without a theoretical understanding of the treatment program and how aftercare
service use relates to the program and to outcomes. Furthermore, this research should
take into consideration the various types of services that can be used and the multiple

outcomes that could be affected.

37

The current study was a theoretical evaluation of one specialized dual disorder
treatment setting. The dual disorder treatment program's intensive and didactic
treatment strategy solicited involvement from the participants by structuring 16 hours of
the participant' s weekday schedule. Participants could not leave the treatment until
they had received the complete treatment regimen. It was believed that since dual
disorder participants had been involved in this intensive treatment they would be more
attuned to or motivate towards service use post discharge (e. g. , they would have more
intentions to use services upon discharge). Due to their exposure to intensive treatment
while in the hospital and active involvement in that treatment, (as well as increased
intentions at the time of discharge) it was hypothesized that they would be more likely
to continue this treatment regimen in the community. Furthermore, increased exposure
to treatment post discharge was thought to have positive effects on outcomes.

This study used a multidimensional model to evaluate the specialized treatment
while considering intentions to use services post discharge, use of formal and informal
aftercare services, and outcomes in Six different domains. Specifically, the dual
disorder hospital program was compared to the standard psychiatric hospital program to
determine if addressing both mental health and substance use problems concurrently
would impact intentions to use services; actual service use; and psychiatric, alcohol
use, drug use, employment, legal, and residential stability outcomes. The following
research questions are posed for this evaluation, and the theoretical model is presented

in Figure 2.

38
Research_Qnestinns

I. Are PLDD who receive specialized dual disorder inpatient treatment more likely to
indicate intentions to continue their treatment beyond discharge, than PLDD who
receive standard psychiatric treatment? A
11. Do PLDD who have intentions to continue treatment after discharge actually use
more formal and/ or AA/N A services than people who do not have intentions?
111. Do PLDD who receive formal and/ or AA/N A services have better psychiatric,
alcohol use, drug use, employment, legal, and residential stability outcomes than
people who do not receive these services?
IV. Do PLDD who receive specialized dual disorder inpatient treatment use more
formal and/or AA/ NA services than PLDD who receive standard hospital treatment
regardless of their intentions to use services?
V. Do PLDD who receive specialized dual disorder inpatient treatment have more
positive psychiatric, alcohol use, drug use, employment, legal, and residential stability

outcomes than PLDD who receive standard psychiatric treatment?

Chapter 2
Methods
The proposed study took place within the context of the Enhancing State
Research Capacity grant funded by the National Institute of Mental Health. This
project was a joint venture of the Michigan Department of Mental Health, Michigan
State University, Wayne State University, the Detroit\Wayne Community Mental
Health Board and the University of Michigan. The purpose of the overall grant was to
evaluate the effectiveness of a dual disorder treatment program at a regional psychiatric
hospital in Northville, Michigan.
Participants
Participants were men and women admitted to Northville Regional Psychiatric
Hospital (NRPH) in Northville, Michigan, from June, 1991, to June, 1992. Eligibility
required that participants screen positive for substance abuse problems. Furthermore,
participants could not be acutely psychotic and needed to verbalize some motivation for
treatment of their substance abuse problems. Participants were excluded from
eligibility if they were severely cognitively impaired, were labeled developmentally
disabled, or if they had Shown violent tendencies or inappropriate sexual activities. Of
approximately 2,806 clients admitted to NRPH during the 12—month period, 535 met

the initial recruitment criteria and were willing to participate in the study. Participants

39

40

were further excluded from the study if they were unable to Spend a minimum of five
days in treatment before discharge. This standard was necessary to ensure that all
participants could receive a minimum threshold of treatment. Other attrition occurred
from participants' refusal (n= 92) and death (n= 8). A total of 391 participants met
the initial recruitment criteria, received the minimum threshold of treatment, and had
70% complete information at the 6—month follow—up interview.

Participants are mostly Black/Afiican American (76%), and male (74%), and
nearly 2/3 are never married (63%). Most have a high school education and have been
charged with a crime (73 %). Approximately one third were unemployed at intake
(33%). Substance abuse diagnoses included alcohol dependence (16%), cocaine
dependence (9 %), and poly drug dependence (29 %). Mental health diagnoses included
the following: schizophrenia (26%), organic mood disorder (17%), adjustment
disorders (13%), mild affective disorders (13%), major depression (7%), bipolar
depression (5 %), and antisocial personality disorders (2 %).

This sample differs from the typical samples reported in the literature review
above in that it contained a large number of individuals who were screened to
determine the presence of a dual disorder, and that these participants were randomly
assigned to receive the dual disorder treatment versus the standard inpatient psychiatric
treatment. This sample was exceptional in that it consisted of persons known to have
had the dual disorder and received the dual disorder treatment. Other studies either

did not assess the participant to determine the dual disorder (e.g. , they used participants

41
with particular diagnoses), or used persons receiving a standard psychiatric treatment
only.

Table 1 compares the experimental and control participants in this study using
the variables under consideration. In this study experimental (dual disorder)
participants tended to have on average longer length of stays; more intentions to use
AA/NA services; more CMI-I, community hospital, and self-help services; and better
employment, alcohol, legal, and psychiatric outcomes than the control (standard

psychiatric treatment) participants.

42

 

 

 

Experimental Control
Study Variables (Dual Disorder) (Standard Psychiatric
Treatment)
Iength of Stay i=5o 2:30
Intent to Use AA/NA 2=3.49 2=3.30
Intent to Manage Mental '
Health Needs 2=3.71 sz=3.7l
CMH Services 2:31 2=22
State Hospital Services ,—.= .09 2:.13
Community Hospital
Services :=.20 2=.20
AA/NA Services 2=3.48 2:200
Employment >2 = . l9 2 = . 17
Alcohol Use 2 — .79 s: = .74
Drug Use 2=.89 2:.89
Legal Problems 2=.84 2=.8l
Psychiatric Functioning 2 = .67 2 = .66 '
Residential Stability sz=.07 2=.07

 

43

At the time of recruitment, those persons agreeing to participate signed an
informed consent form. The study assured participants that all of the information in the
interview and all other data (e.g. , tracking information) would be kept strictly
confidential. Participants were paid for their cooperation with the study. Research
staff randomly assigned the participants to either the dual disorder treatment or the
standard hospital treatment. The ratio of participants assigned to the dual disorder
ward versus the standard treatment was 3:2 respectively.
Design

In the overall study, a randomized experimental design was employed to
evaluate the impact of the specialized dual disorder treatment program. Table 2
presents the critical ingredients of both conditions. The dual disorder treatment
included a more intensive and comprehensive treatment, that immersed participants in
the treatment. Theoretically speaking, it is this immersion that sets the participants up
for continued service use in the community. This immersion was in part due to a series
of 40 educational lectures covering a wide variety of topics specifically of interest and
concern to people with dual disorders. These lectures were intended to provide factual
information, to assist in the changing patient's attitudes about substance use, and to
increase motivation for program involvement and recovery. Other treatment .
components important to this treatment experience include on ward self-help group ,

meetings and continuous aftercare planning beginning at admission. It was behaved

44

that the dual disorder treatment had more effect on the participants making them more
motivated or intent upon using services upon discharge firm the hospital.

The dual disorder ward was compared to the standard psychiatric ward, in this
study, to determine if addressing both mental health and substance use problems
concurrently would impact intentions to use services; actual service use; and
psychiatric, alcohol use, drug use, employment, legal, and residential stability
outcomes.

Table 2

O O O O
l
rrrr..e.rrr l . D .or‘ ‘.rr'r .rc .rr.r r." rmrr'r

 

Dual Disorder Treatment Standard Psychiatric Treatment

 

> Enhanced staffing ratio, staff have > Fewer staff, staff not specially train

substance abuse training in substance abuse -

> Specialized substance abuse > Standard psychiatric care, substance

treatment abuse focus limited to optional AA/NA
meetings

> More intensive treatment > Less intensive treatment

> Patients not released until they have > Patients may leave any time during
completed the entire treatment program treatment program for numerous reasons

> Residents cannot leave the ward > Residents have ground privileges
except for supervised activities
Dual_Disorder_Ireatment. The Mental Illness/ Chemical Dependency Program
provided specialized, co—educational treatment on two, 30-bed wards. The gender
breakdown was three male beds for every two female beds. This treatment

simultaneously addressed mental illness and chemical dependency problems. The ward

45

was oriented toward reduction of recidivism and establishment of the beginning of a
lifelong recovery from chemical dependency. The program incorporated
comprehensive treatment modalities addressing physical, psychiatric/psychological,
family, social/ interpersonal and substance abuse problems.

The program was didactic and intensive -- structuring 16 hours of the patient' 3
weekday with scheduled therapeutic activities. These activities involved psychiatric
treatment, individual/ group psychotherapy, educational lectures, group discussion and
self-help groups, family education, activity therapy, medical services and aftercare
planning. The self-help groups (specifically AA/NA) could be attended by persons
outside of the treatment setting. The NA group was usually lead by an outside
recovering NA member, but most of the time these leaders were also former patients of
the dual disorder program. The AA groups were lead by a recovering hospital staff
member who was also a member of AA. However, additional AA meetings could be
held at any time lead by the dual disorder participants.

Discharge planning for people on the dual disorder ward was more directed and
deliberate than for people on the standard treatment wards. Dual disorder treatment
staff coordinated the treatment needs at discharge to ensure that the participant received
the best care in the community and that they did not go from a highly structured
program to a totally unstructured program in the community. Aftercare planning began
at the time of admission to the unit and continued until discharge from the unit.

Participants were referred to AA/ NA groups in their community where they could

46

attend meetings. They were also instructed verbally and given information on how to
find an AA/NA sponsor in the community, however, the responsibility was on them to
actually follow through with these tasks. The dual disorder treatment also actively
sought placements in mental health and substance abuse (MISA) homes developed in
the community by the CMH board. If there was a position open in one of the houses
the staff entered them in that treatment, if a position was not available they were
referred to other CMH or community treatments for both their substance use and
mental health problems.

Standardlreatment. The standard treatment wards (control wards) differed
from the dual disorder treatment in the following ways: (1) staff did not have special
training in substance abuse, (2) there was a lower staff to patient ratio, and (3) clients
could have left the ward using ground passes. On these wards, participants received
activity therapy, individual and group psychotherapy, and could have received AA and
NA treatment offered by the dual diagnosis ward if the patients requested it. Discharge
planning for these wards was less formal and not as well coordinated with the CMH
services. Participants were given general referrals to follow-up mental health care
and/or substance abuse care in the community, but they were not necessarily directed to
dual disorder treatments.

Procedures
Data_Collectinn. For the overall study, follow—up interviews were conducted at

2, 6, 10, 14, and 18 months post discharge. Interviewers were ”blind" to the

47
experimental condition of the participants at the beginning of the interview process,
although this secrecy was not preserved throughout the entire interview process. The
current study used self report information from the 6 month follow-up. Aftereare
service use data was collected from discharge to the 6 month follow-up. Self-help
aftercare service data was collected by self report at the 2 and 6 month follow-up, but
responses were based on the last 30 days. Therefore, this data reflected self-help
treatment obtained one month prior to the 2 and 6 month interview time points. Data
on intentions to use services were collected at discharge and data on prior psychiatric
functioning were collected at hospital entry. The 6 month follow-up time period was
chosen because it provides the participants enough time to use community services, yet
was not so long as to miss any major psychiatric episodes possibly occurring after a
recent discharge. In reality, the time period chosen for this or any study was somewhat
arbitrary because it is a cross sectional period within the participants' entire treatment
experience. Although, the time period between the baseline interview and the
discharge interview differed between groups because standard treatment participants left
the hospital earlier, the follow-up interviews were consistently spaced, with the follow-
up beginning at discharge for all participants. This study did have a potential treatment
confound in that the length and intensity of the treatment was confounded with the type
of treatment the participants received. For example, participants receiving the standard
treatment ward received a less intensive and usually shorter treatment period than those

receiving the dual disorder treatment. Dual disorder participants were in inpatient

48

treatment an average of 50.8 (SD=32.1) days, and standard treatment participants an
average of 30.8 (SD=25.4) days. In order to control for this treatment effect, length
of stay was controlled for prior to the analyses. Follow-up dates were based on
discharge date rather than admission date because of the different treatment lengths.
Since many longitudinal studies are marked by high attrition, methods in this
study were enacted to assure follow-up interview completion. Tracking information
and releases of information were collected after the baseline interview and confirmed or
updated after the discharge interview. Two release forms were completed, one for
friends and relatives and another for formal service agencies. For the first release
form, respondents provided the names of friends and relatives who the project staff
could contact in the event that the interviewer had difficulty finding them. The other
release form was developed with the Detroit-Wayne County Community Mental Health
Board (D/WCMI-IB) to allow access to clinical records to locate a lost participant. The
D/WCMHB provided service use information for tracking and analysis of service use
patterns. If an interviewer was having a difficult time locating a particular participant,
the D—WCMHB representative would identify the most recent treatment services used.
The representative would then contact the agency or agencies that provided the services
to obtain more information about the location of their client. Interviewers asked
participants where they may have had criminal justice system involvement, received.

previous medical and psychiatric services, attended church, and frequented shelters.

49

New releases and tracking forms were completed after each community follow-up
interview.

Procedures used to limit attrition were highly successful with an 89%
completion rate for the 6 month follow-up period. Procedures for locating participants
in the community were similar to approaches employed by researchers in other
longitudinal studies (Nurco, Bonito, Lerner, & Balter, 1975; Nurco, Robins, &
O'Donnel, 1977; Ribisl, Walton, Mowbray, Davidson, Luke, & BootsMiller, In Press;
Rumptz, Sullivan, Davidson, & Basta, 1991). The project's general tracking-
approaches included the following efforts: make contacting the project very easy and
enjoyable for each participant, reward participants when they contact the project office
by phone or mail, contact participants frequently, reward interviewers for locating
participants and completing interviews in a timely fashion, and dedicate substantial
resources to tracking. The population in this study was generally considered difficult to
locate individuals. Some participants had sparse tracking information because they
either had few friends and relatives, or no stable residence.

If the participant could not be found by the previous approaches, more formal
procedures were employed. The participants' medical records from Northville
Regional Psychiatric Hospital (NRPH) were examined to provide clues as to their
discharge addresses or other helpful information. For example, these medical records
Often contained information about friends and relatives who served as correspondents.

Information about previous incarcerations or the names of probation officers was

50

recorded for persons with previous criminal justice system involvement. The project
also created a "Find List" of all participants who had not been located either after six
weeks or after all tracking possibilities were exhausted. letters addressed to each
person on the Find List were distributed to a local homeless shelter and Salvation Army
shelter. Agreements were made with these agencies that the letters would be
distributed if the participants used the facilities. The Find List was also used with the
county jail and if the participants entered the jail, the project was notified and the D-
WCMHB Jail liaison facilitated the scheduling of an interview. The Find List was also
distributed to the local morgue monthly to help locate deceased participants.
Measures

Psychometric data from the outcome measures of the present study are presented
in Table 3. The proposed measurement model is presented in Figure 3. The dual
disorder treatment was the experimental condition (coded as a two) and the standard
hospital treatment was the control condition (coded as one). Intentions were scored
one, the participant definitely would not use services to four, the participant definitely
would use services. Service use was measured as the total number of services received
by the participant. High score equalled more service use. The employment, alcohol
use, drug use, legal, and psychiatric variables were all ASI composite scores in which a
high score signified more severe or worse outcomes. However, in this study the
direction of the scales were reversed so a higher score reflected better outcomes (e.g. ,

less alcohol use, better psychiatric functioning, more employment, and residential

51

stability). The residential stability variable was a count of the total number of
residence changes the participants reported from the address given at discharge to the
address reported at the 6 month follow-up interview. Therefore, a high score reflects

more residential instability indicating more changes in residences.

52

 

 

Self- AA/NAUse
in Priorto2urd AlcoholUsc
6MonthFollow-ups DnrgUsc

 

 

 

 

 

hummuwlNA/AA mammary
mummhcoldrpmblems WW ,'

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

53

Table 3

Item-total correlations and coefficient alphas of outcome measures

 

 

Scale Mean (SD) No. of II“ Item Total Coefficient
Items Correlation Alpha
ASI Employment Composite .18(.23) 4 387 .30-.58 .64
A81 Alcohol Use Composite .23(. 19) 6 390 .47-.67 .81
A81 Drug Use Composite .08(.06) 5 384 . 18-.70 .70
A81 Legal Composite .20(.18) 5 391 .11—.75 .70
A81 Psychiatric Composite .33L25) 11 391 .28-.79 .81

 

* Number of cases varied due to missing data.

AddicfiomSeueritngndeLLASI). The A81 (McLellan, Luborsky, Woody, &
O'Brien, 1980) composite scores are used in this study to measure employment, alcohol
use, drug use, legal problems, and psychiatric functioning, (see Figure 3) at the 6
month follow-up interview. This instrument (see Appendix A) is a clinical/research
instrument that assesses the severity of seven unique problem areas commonly found in
patients with alcohol and substance abuse. These six domains are Medical,
Employment, Legal, Drug/ Alcohol, Family/ Social, and Psychiatric. For the first
section of each area, participants are asked several objective and potentially verifiable
questions about their problem symptoms. In the latter portion of the section,
participants provide subjective information about the extent to which they have been
bothered by these problems and the importance of treatment based. All composite .

scores were reversed so that high total scores reflect better outcomes.

54

The original ASI document showed that the ASI Alcohol and Drug Composite
scores were significantly correlated with the number of overdoses, total years of regular
use of alcohol/drugs, and the amount of money spent on alcohol/drugs per week.
Evidence for concurrent validity has also been provided (Kosten, Rounsaville, &
Kleber, 1983; LaPorte, McLellan, O'Brien, & Marshall, 1981). According to the
authors, average concordance between trained interviewers is . 89 and the interview has
adequate test-retest reliability. Some caution is warranted when applying this measure
to persons with dual diagnoses because this measure has not yet been validated with this
population (Ridgely, Osher, & Talbott, 1987). Coefficent alphas from the current
study are presented in Table 2.

IntentionsJoJIseSemices. Intentions to use services was measured at discharge
and assessed by two items (see Appendix B) from the discharge interview that asked if
the participants, (I) intended to use Alcoholics Anonymous (AA)/Narcotics
Anonymous (NA), and (2) intended to manage their mental health needs. These items
were scored 1 = definitely will not use services and 4 = definitely will use the
services. High score reflects intentions to use services.

AftercareSenricellse. The mental health service utilization of participants
from the D/WCMHB and the community hospitals as assessed through the
computerized records of the D/WCMHB. In these records, information was recorded
for every service event the participants received from agencies and community hospitals

under the authority of the D/WCMHB. The types of services included in thisdata

55

included the following: screening, pre-intake, direct and indirect general outpatient,
case management, partial hospitalization, day hospitalization, and residential treatment.
The types of services that are lacking from this data include Verteran's Affairs services,
emergency services, medical services, and services provided by friends, relatives, and
clergy. This data was collected from the time of discharge to the time of the 6 month
follow-up interview time point. 1

State hospital service utilization was obtained from the computerized records of
the Michigan Department of Mental Health. Information was recorded for every state
hospital admission that the participants received between discharge and the 6 month
follow—up time point. Self-report AA/ NA service use was measured at 2 and 6 months
using two questions from the 2 and 6 month follow-up interviews (see Appendix C)
that asked the number of times the participants used AA or NA in the past month. In
this study informal service use was AA/NA service use and formal service use included
CMH community, state hospital, and community hospital services. For all service use

variables a high score reflected more service use.

Chapter 3
Results

A series of hierarchical multiple regressions were conducted using several
variations of the service use variables to attain meaningful path coefficients for the
model as presented in Figure 2. First, this section provides a brief overview of the
preliminary analyses completed. Second, the hierarchical multiple regressions that
were used to obtain the standardized path coefficients for the final model are presented.
Third, the significant direct and indirect pathways leading to the outcome variables at
the 6 month follow-up time period are explained and discussed as well as other findings
and the final path model is presented, trimmed of nonsignificant pathways. Since the
original research hypothesis were one tailed, one tailed statistically significant
coefficients are included in the model and discussion, however, Tables 4, 5, 6, and 7
include the beta weights and effects for all variables.

Hierarchical multiple regressions (see Cohen & Cohen, 1983) were conducted
on several variations of the service use variables to attain meaningful path coefficients
for the model. Since analyses from the larger study presented in Figure 1 had indicated
a relationship between experimental condition and length of stay, length of stay was

used as a covariate to guard against the confound between treatment type and length of

56

57

stay in all the following analyses. In the first analysis, dichotomous service variables
for CMH outpatient services, State hospital admission, community hospital admission,
and AA/NA services were used in the model to reflect the use and non-use of services.
This analysis produced a few direct paths, but no indirect pathways that would explain
the relationship between the different domains.

Second, a cluster analysis was conducted to distinguish the groups by both
amount and type of services. This analysis produced fewer significant direct pathways
than the first analysis and no indirect pathways. It was also noted that the clusters were
similar to the original variables grouped by type of service use. A description of the
clusters obtained in this analysis is described in Appendix D.

Third, continuous service variables (e. g. the total number of services received)
were used to reflect the amount of services used. This analysis yielded the most
conceptually meaningful and clear relationships between the variables.

Research question one asked if PLDD who received Specialized dual disorder
inpatient treatment were more likely to indicate intentions to continue their treatment
beyond discharge than PLDD who received standard psychiatric treatment. The two
paths from assignment (D =.18, {K .05) and from length of stay (the covariate) (B =
.18, p< .05) to intent to use AA/NA, were the only significant pathways addressing
this question. This result showed that people who received the dual disorder treatment

(experimental assignment) had more intentions to use AA/NA services than persons

58

receiving the standard psychiatric treatment. Table 5 shows the Beta weights for the
intent to use AA/NA and intent to manage mental health needs by assignment and
length of stay.

To investigate the possibility that the high intention group in the control group
may serve as a proxy for some of the most important variables, the regression analysis
were run with only the control group. However, this analysis did not contribute any
pertinent information to the findings. There was no relationship between assignment
and intentions. Intentions to use AA/NA in the control group was related to use of
more community hospital services and intentions to manage mental health needs was
related to more CMH service use. Furthermore, there was a negative relationship

between CMH service use and residential stability.

 

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60

B . Es . II It’ll

The second research question inquired if PLDD who have intentions to continue
treatment after discharge actually use more formal and/or AA/NA services than people
who do not have intentions. The significant pathway from intention to use AA/NA to
actual AA/NA service use (6 =.10, p< .05) answered this question. Persons who had
intentions to use AA/NA services used more AA/NA services than persons who did not
have such intentions.

The fourth research question, do PLDD who receive specialized dual disorder
inpatient treatment use more formal and/or AA/ NA services than PLDD who receive
standard hospital treatment regardless of their intentions to use services, was not
answered affirmatively. People who received the dual disorder treatment (experimental
assignment) did not use significantly more services than the people who received the
standard psychiatric treatment (control assignment). However, the pathway from
length of stay (the covariate) to CMH services (B =.22, p < .05) was significant. Table
5 shows the Beta weights for all the service use variables predicted by intent to use
AA/NA, intent to manage mental health needs, assignment, and length of stay.
Regressionsofflutcomeflariables

The third research question asked if PLDD who received formal and/or AA/N A
services have better psychiatric, alcohol use, drug use, employment, legal, and
residential stability outcomes than people who do not receive these services. A

significant pathway was found from AA/N A service use to psychiatric functioning

61

(B = .19, p < .05). Table 6 shows the Beta weights for the outcome variables predicted
by CMH service use, state hospital service use, community hospital service use,
AA/NA service use, assignment, and length of stay. No other Significant positive
relationships were found. However, other findings not stated apriori indicated that the
reverse relationship may have occurred.

While not in the predicted direction, some results were seen from community
hospital services to employment (13 =-.12, p< .05), from state hospital services to
psychiatric functioning (B =-.12, p < .05), and from CMH services to residential
stability ((3 =-.12, p< .05). People who received AA/NA services had less severe
psychiatric problems. Yet, those who received community hospital services and state
hospital services may have had more employment and psychiatric problems, '
respectively. Participants who used CMH services may have had greater residential
instability.

The fifth research question was to determine if PLDD who received specialized
dual disorder treatment have more positive psychiatric, alcohol use, drug use,
employment, legal, and residential stability outcomes than PLDD who received
standard psychiatric treatment. Direct effects showed that people who received the dual
disorder treatment (experimental assignment) did not have significantly different
outcomes from those who received the standard treatment (control assignment).
However, there was a Significant pathway from length of stay to alcohol use (8 =.13.

p < .05). This result was independent of the treatment group because length of stay was

62

used as a covariate. The model with all the significant one tailed pathways and beta

weights is presented in Figure 4.

63

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65
IndirecLEathsandlotaLEffects

Indirect effects are calculated by multiplying the beta weights that fall along the
indirect pathway. Table 7 summarizes all the indirect and total effects on the outcome
variables. One indirect path was from assignment, to intention to use AA/NA (B =.18)
to AA/NA service use (B =.10), to psychiatric functioning ([3 =.19). The indirect path
resulted in a beta weight of .003. A similar path from length of stay, to intention to
use AA/NA (B =.18) to AA/NA service use (B =. 10), to psychiatric functioning
(B =. 19) produced the same beta weight .003. Only one other indirect effect was
found from length of stay to CMH service use (B =.22), and to residential stability
(B =. 12), which produced a nonsignificant indirect effect of B = .03.

To determine the total effect, the direct effect is added to the sum of all the
indirect effects. In this study the total effects were not as strong as the direct effects.
The total effects for length of stay were -.13 for alcohol use, .16 for psychiatric
functioning, and .03 for residential stability. There was a total effect of .003 for
assignment via intentions to use AA/NA service use by actual AA/NA service use and a
total effect of .02 for psychiatric functioning by the same route. Other total effects
merely reflect the direct effects with no other additions. All total effects for the two
tailed pathways are presented in Table 6.
31mm

In sum, results of this study showed that receiving dual disorder treatment was

related to having more intentions to use AA/NA services and also related to AA/NA

66

services in the community. As a result these the use of AA/NA services was related to
better psychiatric functioning. Other types of service use not only were not related to
positive outcomes, but may have been associated with worse employment, residential

stability, and psychiatric functioning outcomes for participants.

67

Table 7
Direct, Indirect, and Total Effects on Outcome Variables

 

 

 

Outcome Variables
Independent Variables . . . .
Employment Alcohol Psychiatric Resrdentral
Use Functioning Stability
Length of Stay
Direct Effect - .13 -. l6 -
Indirect Effect -
Via CMH Services - - -- -.03
Via Intention to Use
AA/ N A Services and
AA/NA Service Use - - .003 -
Total Effect - .13 -. 16 -.03
Assignment
Direct Effect - - - -
Indirect Effect -- -
Via Intention to Use
AA/N A Services and
AA/N A Service Use - - .003 -
Total Effect - - .003 -
Intention to Use AA/NA Services
Direct Effect - - - --
Indirect Effect
Via AA/NA Service -- -- .02 -
Use

Total Effect - - .02

 

68

 

Outcome Variables

 

Independent Variables
Employment

Alcohol
Use

Psychiatric
Functioning

Residential
Stability

 

CMH Service Use
Direct Effect -
Indirect Effect -
Total Effect -

State Hospital Service Use
Direct Effect -
Indirect Effect -
Total Effect -

Community Hospital Service Use
Direct Effect -. 12
Indirect Effect -
Total Effect -. 12

AA/N A Service Use
Direct Effect -
Indirect Effect -
Total Effect --

-. 12

-. 12

.19

.19

-. 12

-. 12

 

Note: - Indicates that the path was either not tested or not significant using a two tailed test of

significance.

Chapter 4
Discussion

The results of this study demonstrated that a theoretically based,
multidimensional evaluation was useful in assessing outcomes of PLDD who were
admitted to a specialized dual disorder program. This study was ground breaking in
that it was able to assess the use of several different types of services upon discharge
from a state psychiatric facility and relate this use to prior treatment and multiple
outcomes. Although the start and end points of this research were somewhat arbitrary
when compared to the entire treatment lifetime of the individuals, it was noteworthy
that this study depicts a larger picture than previous studies, of service use and the
impact on multiple outcomes.

This study did not conclude that receipt of the specialized dual disorder
treatment directly related to more aftercare service use. However, this study did reveal
that the use of a theoretical evaluation was important in identifying variables that
mediated outcomes. If a theoretical evaluation had not been used, these variables may
not have been considered in relation to outcomes, rather they may have been related
only to the treatment program and aftercare services. N ever-the-less, the variables of
intention to use services and aftercare service use acted as mediators of 6 month .

outcomes for PLDD.

69

70

Evahrafiongflthekesmrchnuesfions

The first research question asked if PLDD who received specialized dual
disorder inpatient treatment were more likely to indicate intentions to continue their
treatment beyond discharge than PLDD who received standard psychiatric treatment.
The second question inquired if PLDD who had intentions to continue treatment after
discharge actually used more formal and/or AA/N A services than people who did not
have intentions. The results indicated that people in the specialized program did have
intentions to use AA/NA services, but they did not have intentions to manage their
mental health needs. Further, the current model supported the notion that intentions to
use AA/NA was related to use of AA/NA services post discharge.

These results could reflect a sense of membership in AA/NA instilled in the
participants by the formal treatment program. Since the participants attended AA/NA
as part of the formal treatment program, this no doubt contributed to their intentions to
continue this type of service and motivated them to continue this treatment once they
were discharged from the hospital. Some literature suggests that intensity of
involvement in AA is related to the degree of comfort participant felt in the group
(Kurtz, Garvin, Hill, Pollio, 1995). Machell (1992) also found that the AA concept of
”fellowship” or ”client perceived belongingness" was a significant factor in successful
psychological treatment outcome and good mental health. If dual disorder participants

were comfortable in the AA group they attended in the hospital and or felt that they

71

belonged, this could have made attending meetings in the community easier. The
transition from inpatient to outpatient AA treatment could have been facilitated by the
sense of membership and comfort already established with the group.

Another explanation could be that the people on the dual disorder ward were
more likely to be linked to AA/NA services in the community via discharge planning,
since participants on the dual disorder ward were made aware of AA/N A services and
instructed how to connect with a sponsor in their community. Therefore, seeking
treatment was not as complicated or difficult for them.

In addition, direct contact with outside NA members while in inpatient
treatment may have also facilitated this link with outside NA services, establishing
contact with community NA members prior to discharge from the dual disorder ward.
This information contrasts the literature which states that PLDD are noncompliant with
treatment (Wolpe, Gorton, Serota, & Sanford, 1993) and resist available services
(Howland, 1990 ), yet it supports work stating that PLDD need more flexible types of
care (Amann & Harris, 1992). Perhaps the barriers to formal treatment (Howland,
1990; Ridgely, Goldman, Willenbring, 1990; Stefl & Properi, 1983) are too difficult
for these people to overcome and self-help services, although not a perfect treatment
match, are more easily accessed and assimilated by the participants than the formal
services.

The third research question asked if PLDD who received formal and/ or AA/NA

services had better psychiatric, alcohol use, drug use, employment, legal, and

72

residential stability outcomes than people who did not receive these services. This
study revealed that receiving AA/NA services was related to better psychiatric
functioning. However, some findings seemed to indicate the following: receiving more
CMH services was not related to residential stability, receiving more state hospital
services was associated with worse psychiatric functioning, and receiving more
community hospitalizations tended to produce more employment problems. These
findings seem to contradict some of the AA literature that suggests people attending AA
after treatment are more likely to be sober (Hoffman & Miller; 1992), but agree with
literature stating that self-help attendance after more formal treatment (e. g. day
hospital) predicted better outcomes (McKay, Alterman, Me Lellan, Snider; 1994).

One possible explanation could suggest that the relationships in the current
model are actually the reverse of what is stated (causality is in the opposite direction).
Perhaps the individuals outcomes were the impetus for them to receive particular
services. It could be that pe0ple suffering with worse psychiatric functioning sought
out treatment at the state psychiatric hospitals because of their reduced functioning and
that people with residential instability sought out CMH services for help with this
problem. These alternative explanations need to be investigated further to determine if
persons are receiving service only when they are forced to by their psychiatric,
physical, or social conditions.

Several studies in the literature investigated service use (Drake et al. 1993;

Solomon, 1986; Jerrell and Ridgely, 1995; Hoffman, et al., 1993; Clopton et al.,

73

1993), but literature investigating this link between service use and outcomes is lacking
(Bond et al., 1991). This is unfortunate because service use is an important component
of the overall treatment process. Service use can effectually extend treatment and
become part of the overall treatment process. The current study suggests that it is
important to evaluate the type of services participants' received post discharge and the
related outcomes. As evidenced by this research, all services may not be related to the
same type of outcomes and all types of outcomes may not be effected by service use.

The fourth and fifth research questions asked if PLDD who receive specialized
treatment used more formal and/or AA/ NA services than PLDD who received standard
treatment regardless of their intentions to use services, and if PLDD attending the
specialized treatment had more positive outcome regardless of intentions or service use.
None of these relationships were confirmed when length of stay was controlled.
SupportfoLtheIheoretiraLModel

In this study the theoretical model suggested that PLDD who participated in a
specialized dual disorder treatment would have more intentions to use services post
discharge, would actually use more services, and therefore, would have better related
outcomes than PLDD who received standard psychiatric treatment. This model was
confirmed with regard to intention to use AA/NA services and actual use of AA/NA
services and psychiatric outcome. Persons who received the dual disorder treatment
had fewer intentions to use AA/NA services, used more AA/NA services, and showed

better psychiatric functioning at 6 months. The length of stay, entered as a covariate,

19

for
CV:

inn

74

showed a second related path which demonstrated that people who were in treatment
for a shorter period had intentions to use AA/NA services. Prior studies instead of
considering the entire treatment process, only considered one piece of the process (e. g. ,
type of treatment, service use, or outcomes).

When length of stay was controlled another relationship was evident from length
of stay to CMH services. This finding appeared to indicate that people who remained
in the hospital longer used more CMH services after discharge. Although Case (1991)
and Lyons and McGovern (1989) noted that PLDD leave treatment earlier than PLMI
and PLDD have more hospitalizations post discharge, the current study suggests that
retaining PLDD in treatment assisted them in connecting with community services.
This finding is in agreement with some AA literature (Farris—Kurtz, 1981) which states
that there is a relationship between time in treatment (residential community program)
and participation in AA. Yet, unlike Pals-Stewart and Schafer (1992) this research did
not find that length of stay had any impact on substance use.

Extensiomoffarlyflork

This project was one of the few and more recent studies (Blankertz & Cnaan,
1992; Drake, McLaughlin, Pepper, & Minkoff, 1991; Weiss & Collins, 1992; Weiss
& Mirin, 1989) that evaluated the effectiveness of a specialized dual disorder treatment
for PLDD. Furthermore, it used a theoretical model which helped to structure the
evaluation around expected treatment effects and determine the mediating effects of

intentions and service use on outcomes. Multiple measures of service use and

tr:

fil

PS

7S

outcomes were used which was an improvement over earlier research (Bond et al. ,
1991; Case, 1991; Drake et al., 1993; Pal-Stewart & Shafer, 1992; Lyons &
McGovern, 1989; Munsey et al., 1992; Reis & Ellingson, 1990; Solomon, 1986-87).
A large sample was also an improvement over other studies and a great asset.

As a result of these improved methods and strategies, this study found that dual
disorder treatment cultivates intentions to use services. Persons in the dual disorder
treatment had more intentions to use AA/NA services and actually used more of these
services than people receiving the standard psychiatric treatment. As stated above these
findings contrast the literature which states that PLDD are noncompliant with treatment
(Wolpe, Gorton, Serota, & Sanford, 1993) and resist available services (Howland,
1990 ), yet it supports work stating that PLDD need more flexible types of care
(Amann & Harris, 1992). In general, if treatment can stimulate the participants and
involve them, they may begin to think of their lives and treatment issues after
discharge. Inpatient treatment could contribute to the AA sense of ”fellowship” or
"belongingness" (Machell, 1992), thus stimulating people to maintain this group
involvement upon discharge.

Nonetheless, the measurement of multiple community services revealed that
persons discharged from the hospital were not necessarily following-up with psychiatric
treatment in the community. It is possible that these people received other services, but
it is disconcerting that participants had not received some type of CMH services after a

psychiatric hospitalization. Barriers to formal treatment (Ridgely, Goldman,

76
Willenbring, 1990; Howland, 1990; Stefl & Properi, 1983) could be keeping PLDD
from accessing services. Perhaps services are too difficult for these people to locate
and access, or perhaps these services do not meet the needs of PLDD so they do not
feel comfortable in the psychiatric service network. Self-help services may be less
intimidating and more easily accessed.

It was somewhat surprising that use of AA/NA services was related to
psychiatric outcomes and yet not related to improved alcohol use or drug use outcomes.
Although, some AA/ NA studies have shown positive psychological effects most of the
positive outcomes are seen in drug/alcohol use (Hoffman; 1983 and Thurstin, Alfano,
& Nerviano; 1987). These results were also disheartening in that other findings
seemed to suggest negative outcomes as a result of service use. If this is the case, it
could be that after receiving the initial hospital service these people were still in a state
of crisis and therefore, did not show positive outcomes. Perhaps assessing outcomes
after a specified time lag would show more positive outcomes. More work is needed to
evaluate the relationships between services and outcomes for this population.

It should be noted that the larger research project investigated this same path
model controlling for prior psychiatric functioning as well as length of stay. These
analyses, however, did not produce any results contrary to the ones reported and

discussed in this study.

77

121.11..

One goal of this study was to use a theoretical evaluation to assess the service
use and outcomes of PLDD. The model revealed that dual disorder treatment aided in
linking people to aftercare services by inspiring intentions to use aftercare services.
Since the intentions to use AA/NA services led to actual use of these services, PLDD
in the dual disorder treatment seemed to have an advantage over other PLDD. In some
way the dual disorder treatment encouraged continuity of services post discharge. This
is important from a policy standpoint. If the goal of mental health policy is to
encourage the continuity and consistency of care, this study has identified a component
that could be important to maintaining that relationship. More research should
investigate what components of the dual treatment helped to forge these intentions, so
these components can be added to other treatment settings. Furthermore, research
needs to look more at motivation and its connection to service use. Since intentions is
a specific form of motivation, and since people need to be motivated in order to use
self-help (Ditrnan et a1. , 1967) this connection is very important.

Since this study found only one positive outcome as a result of the services
under investigation, other services such as medical and dual disorder aftercare services
should be investigated and/or implemented to determine if these services would produce
more positive outcomes. Dual disorder programs in the community are a logical next
step in investigating this treatment process. Since PLDD come from integrated

treatment and are discharged mainly to psychiatric or substance abuse treatment, this

78

practice may cut short possible treatment effects that were started in the inpatient
treatment. By separating the treatments post-discharge, pressure is put back on the
PLDD to manage their dual problems is separate treatment systems. Since it has
already been noted that the combination of day hospital treatments and self-help has
produced superior outcomes (McKay, et al.: 1994), the investigation/implementation of
post-discharge dual disorder treatments could reveal that the combination of inpatient
stabilization and dual disorder treatment, with specialized dual disorder aftercare
treatment is superior in creating more positive outcomes for PLDD. Policy makers
should consider the entire treatment process and where-treatment break-down occurs
before cancelling specialized dual disorder programs due to lack of positive outcomes.

Although this study improved upon the previous literature by including
intentions to use services and actual service use in relation to several outcome
measures, other limitations are apparent. The Addiction Severity Index outcome
measure used in this study to measure psychiatric, employment, drug, alcohol and legal
outcomes, asks participants about their activities for the prior 30 days. Outcomes in
this study were assessed at 6 months post discharge (inquiring about the last 30 days).
Since service use was measured from discharge to 6 months post discharge there is
potentially a 30 day overlap of service use and outcome measurement. This .

measurement could have contributed to negative outcomes noted in relation to service

use. Furthermore, the Addiction Severity Index measure is self report and may have

79

suffered from some form of self-report bias. For example, biochemical verification
techniques (e. g. urine screens) were not used to double check the accuracy of self
report drug/alcohol use. Although these other measures were not used, the Addiction
Severity Index is well validated and has been shown to be related to independent
indicators of the problem areas.

It should be made clear that the measurement method used could be a strong
alternative explanation for the results of this study, since effects were found on self-
report measures but not on any of the archival data utilized from the CMH, state, or
community data sets.

Results of this study are only generalizable to an urban, predominantly lower
socioeconomic status population. This study had more African American participants
and fewer schizophrenics when compared to other dual diagnosis research (Kay,
Kalathara, & Meiner, 1989; Lyons & McGovern, 1989).

Euturellesearch

Future research needs to consider other types of aftercare services that could
possibly impact outcomes. As stated above, other types of community services not
specifically identified in this study such as aftercare dual disorder treatment, medical
services, other support groups, and religious groups need consideration. It could be
that dual disorder inpatient treatment is a positive treatment experience if it is followed
by dual disorder treatment in the community. Since there is such a demand in the

literature for specialized dual disorder inpatient programs (Brower, Blow, & Beresford,

80

1989; Drake et al., 1991; Minkoff, 1989; Mueser, Bellack & Blanchard, 1992; Osher
& Kofoed, 1989; Ridgely, 1991; Sciacca, 1991; Weiss & Mirin, 1989), it seems a
logical next step to continue these services in the community as follow-up treatment.

This study does not suggest that inpatient dual disorder treatment should be
cancelled and dual disorder treatment entirely moved to the community. Rather a
combination of impatient and outpatient treatment would seem to be the best
combination. This continuum of treatment may be most beneficial because PLDD
would have the structure and support of the impatient setting while they move out of
their crisis state, and then maintain the necessary support and structure as needed on an
outpatient basis to prevent further relapses. If inpatient dual disorder treatment is
followed by dual disorder outpatient treatment in this respect participants would not be
discharged into a setting where they bear more of the burden for managing and
combining their treatment. Medical services, other support groups, and religious
groups could also have some impact on outcomes and this impact needs to be clearly
delineated in relation to the services and outcomes investigated in this study.

Outcomes should also be assessed at a specified time post service receipt in
order to test for the delayed effects of services. For example, outcomes would be
measured three months after a particular service was received. The current study did
not identify exactly when the services were received in relation to the outcome

measurement. If services were received directly prior to the outcome measurement,

81

poor outcomes would be expected. A more clearly defined time-line of service receipt
and outcome measurement is needed.

The components of treatment that may impact service use need more
clarification. This study found that intentions to use services related to actual service
use, yet numerous other treatment components may have an impact on service use such
as, attitudes toward substance use or drinking (Faulkner, Sandage, Maguire, 1988;
Lind, 1988) or motivation (Miller, 1985). Also necessary, is an investigation into how
the dual disorder treatment inspired intentions to use services. Finally, future research
needs to examine more closely the relationship between service use and outcomes.

This is a complex relationship that may be influenced by factors other than service use.
Conclusions

The results of the current study suggest that theoretical evaluations are helpful in
identifying the process of treatment that occurs after an inpatient psychiatric treatment.
PLDD receiving a specialized dual disorder treatment exhibited more intentions to use
AA/NA services and used more of these services post-discharge than PLDD receiving
standard psychiatric treatment. The effects of multiple types of services (both formal
and informal) on outcomes are also important to consider. This study noted that
intentions to use AA/NA services and actual use of AA/NA aftercare services
contributed to positive outcomes. However, the relationships between formal service

use and outcomes did not produce positive outcomes.

82

In conclusion, these findings may be useful in describing the treatment process
and outcomes of PLDD. Future research should consider other treatment components
besides intentions to use services, and other types of service use (e.g. medical and dual

disorder) that could influence outcomes.

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McLellan, A. T. (1986). ”Psychiatric Severity" as a predictor of outcome from

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McLellan, A. T., Luborsky, L., Woody, G. E., & O'Brien, C. P. (1980). An
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alcoholism. BntrshloumaLoLAddrcM 84-107.

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Mosher, L. R. (1991). Soteria: A therapeutic community for psychotic persons.
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Mueser, K. T., Bellack, A. S., & Blanchard, J. J. (1992). Cormorbidity of .
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Narrow, W. E., Regier, D. A. ,,Rae D. S., Manderscheid, R. W. &Locke, B. Z.
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91

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EsychiangaAAa), 45-49.

APPENDIX A

APPENDIX A

”1.. s .1!“
A81

 

REMEMBER THAT AN 'N" MEANS ”NOT APPLICABLE TO THE PARTICIPANT" AND 'X' MEANS
THAT THE PARTICIPANT CANNOIIINDERSIAND OR WE THE QUESTION. WHEN
ASKING “CUMULATIVE" QUEsnONS, THE TIME FRAME OF THE LAST mTEerEw WILL BE Em-IER 2
MOS. FOR THE lsr FOLLOW-UP OR 4 MOS. FOR ALL OTHER FOLLOW-UPS. To HELP THE
PARTICIPANT, PLEASE MENTION THIS TIME FRAME.

CEOl) Have you been in a controlled environment in the past 30 days?

 

No (WRITE ”N” FOR NEXT QUESTION) 1
Jail 2
Alcohol or Drug Treatment 3
Medical Treatment 4
Psychiatric Treatment 5
Other (SPECIFY ) 6
CE02) How many days? Days
Medical Status

 

First. we would like to start of asking you some questions about your health.

M801) Since your last interview, how many times have you been hospitalized fiJr medical
problems? (INCLUDE OVERDOSES, DELIRIUM TREMENS (DT'S), NOT

DETOXIFICA'I'ION) ........................................ TIMES
M804) Are you taking any prescribed medication on a regular basis fir a physical problem?

Yes .................................................. 1
No .................................................. 0

M806) How many days have you experienced medical problems in the past 30
days? ................................................ DAYS

93

94

For these questions I will ask you to use a scale to let me know how bothered you have been by
Medical problems. I will ask you how bothered you have been by particular problems in several
of the other sections of the interview. Also, I will ask you how important you feel treatment is for
each area being discussed. The scale that we will be using for both types questions looks like this:

HAND PARTICIPANT CARD #1 - PATIENT RATING SCALE
I want you to blow that although I ask how important treatment is to you, I cannot or will not refer
you for any services, since the information that you tell me is confidential. We ask these questions
because we want to know the types of services people are interested in and how important these
services are to them.

FOR THESE NEXT Two QUESTIONS USE CARD #1 - PATIENT RATING SCALE

MS07) How troubled or bothered have you been by these medical problems in the past 30 days?

Not at all (M808, ”Can I assume tx isn't needed"?) ................... 1
Slightly ............................................... 2
Moderately ............................................. 3
Considerably ............................................ 4
Extremely ............................................. 5

M808) How important to you now is treatment for these medical problems ?

Not at all .............................................. 1
Slightly ............................................... 2
Moderately ............................................. 3
Considerably ............................................ 4
Extremely ............................................. 5

Confidence-Ratings: IS THE ABOVE INFORMATION SIGNIFICANTLY DISTORTED BY:

M810) Patients's misrepresentation?
Yes (FocPLArN) .......................................... 1
No .................................................. 0

M81 1) Patient's inability to understand?
Yes (EXPLAIN) .......................................... 1
No .................................................. 0

95

Employment/Support Status

 

E804) (Have you ever driven a car?) Do you have a valid driver's license?

Yes .................................................. 1
No (MARK ”NO" FOR NEXT QUESTION) .......................... 0

E805) Do you have an automobile available f0" use?

What is your usual (or last 3 years) occupation? ~
(SPECIFY IN DETAIL ) {"Homemaker" = 7 and
”Unemployed” = 7}

 

E807) (HOLLINGSHEAD CATEGORY - ITO 7 OR "N " FOR NEVER EMPLOYED) . . .
RATING

E808) Does someone contribute to your support in any way ?

Yes .................................................. 1
No (MARK ”N" FOR NEXT QUESTION) ............................ 0

E809) Does this constitute the majority of your support?

Yes .................................................. 1

No .................................................. 0

E811) How many days were youpaidfirr working in thepastiadays?

(INCLUDE "UNDER THE TABLE WORK") ........................... DAYS

E812) Do you work in exchange for other services, for instance your room and board?

NoaPNOTHENESBIsN) .................................. 0
Yes (ASK E813) ......................................... 1
E813) What is the value of these services? ......................... 5

How much money did you receive firm the following sources in the pastjadays? (ROUND OFF TO
NEAREST DOLLAR)

E814) Employment (Net Income) ............................... 3

E815) Unemployment Compensation ............................ 8

E816) Welfitre (e.g. GA, ADC or AFDC) ......................... S

96

E817) Social Security (SS1 or SSDI), Pension, benefits ................. 3

E818) Mate, family or friends (Money for personal expenses) ............ 5

E819) Illegal (Drug dealing, stealing, "fencing" stolen goods, or illicit
'gambling") ............................................ 8

Adequacy of Financial Support

In the pastmnmontbs, have you had enough money each month to pay fiJr the firllowing things?
Please answer "Yes " or "No " for each one.

Have you had enough money for. .. ?

 

M l

 

Clothing 1
Rent and Utilities 1

Current medical needs - Medical Care and l
Medications

 

 

coco
2222
><><><><

 

Getting to places that you have to go, such as l 0

work, appointments, or grocery shopping?

(e. g. having money for bus fire or having gas
money)

Traveling to visit fiends and @‘Q 1 0 N X

Social activities, that is the things you do for l 0 N X
fun, such as eating in restaurants or seeing a
lovie

Z
N

 

 

 

Being able to pay other people for the money 1 0 N X
that you owe them - (Financial obligations to

others - personal debts)

 

 

 

 

 

 

 

E823) How many days have you experienced employment problems' In the pastja
data?

HAND PARTICIPANT CARD #1 - PATIENT RATING SCALE

97

E824) How troubled or bothered have you been by these employment problems in the past 30 days?

Not at all
(E825 "Can I assume counseling isn't needed'?) ..................... 1
Slightly 2
Moderately 3
Considerably 4
Extremely 5
E825) How important to you now is counseling firr these employment problems?
Not at all 1
Slightly 2
Moderately 3
Considerably 4
Extremely 5
ConfidenmRatings: IS THE ABOVE INFORMATION SIGNIFICANTLY DISTORTED BY:
E827) Patients‘s misrepresentation?
Yes (EXPLAIN) 1
N o 0
E828) Patient's inability to understand?
Yes (EXPLAIN) 1
N o 0

Drug and Alcohol Use

 

These next questions ask you about your use of drugs and alcohol. Once again I would like to
remind you that your answers will be held strictbLmrIfidential.

98

-
input

 

 

 

 

 

 

 

Atlall: : :l 3 use Beer, Wine, Liquor, grain (Read These
a
Categories)
Alcohol - To " " (To feel the effects of alcohol) 02
Intoxication
Heroin 03
, Methadone Methadone, Dolophinc, LAAM 04
‘ Other opiates! Pain Killers: Morphine, Dilaudid, Demenol, os
anal 68108 Percocet, Percodan, Dis-Que], Darvon, Darvocet,
g Talwin, Codeine (Tylenol 24), Syrups (Robitussin,
Aetifed-C),
Barbituates Nembutsl, Seconsl, Tuinol, Amytal, Pmnn, 06
, Secobarbital, Phenobarbital, Fiorinol, Doridcn,
Placidyl 5
1
Other sedative] Bamdiaupines: Valium, Librium, Ativan, Serax, 07 i“
‘ - Tranxene, Dalmane, Halcyon, Xanax.
‘ hypmt,‘98/ Bhenathiazina: (Antipsyehotics): Thorazine, ‘
‘ Wm“ Stelazine, Haldol, Navane, Serentil,Melari1, 1
‘ Prolixin, Compazine. ;
Other: Chloral Hydrate (Noctec), Tofranil, l
Quaaludes. l
Cocaim Cocaine” crystal, free-base cocaine or ”crack," "rock 08 1
: cocame l
; Amphet-amines Monster, Crank, Benzedrine, Dexedrine, Ritalin, 09 r
, mm") Preludin, Methamphetamine, Speed, Ice (”Crystal”) ‘
‘ Cannabis Marijuana, Weed, Pot, Doobie, Hashish 10 y,
' I
‘1. Hallucinogem LSD (Acid), Meecaline, Mushrooms or 'Shrooms" ll ,
, (Psilocybin), Peyote, Green, PCP (Phencyclidine), l
Angel Dust l
‘ Inhalams Nitrous Oxide, Amyl Nitrate (Whippets, Poppers), 12 I
it glue, solvents ;
i ,
3 More than one 13 l
i substance/day '
J

 

 

 

 

 

 

 

 

 

 

Note: Dilantin (an anticonvulsant), Antabuse, Trexan, (for High Blood Pressure) Catapres &
Hydracholorathizide, Ventolin Inhaler & Theodur (for Asthma), Desipramine, Prozac & Sinequan
(Antidepressants), Tagamet & Zantac (Ulcer Meds), Lithium {bicarbonate} (Bipolar disorder)-—
THESE DRUGS DO NOT 00 IN TABLE, BUT PRESCRIPTIONS DO.

99

DR 14) Which substance is the major problem?
(WHEN NOT CLEAR, ASK RESPONDENT - CIRCLE ONE NUMBER IN TABLE BELow)

 

 

   

-
1. Alcohol 6. Barbituates 10. Cannibis 16. Polydrug (2 or

 

 

 

 

 

 

 

 

 

 

 

more dru
3. Heroin 7. Other 11. Hallucinogen 00. No Drug
SedlI-Iyp/I'ranq Problem
4. Medndone 8. Cocaine 12. Inhaler“ NOTES:
5. Other 9. Amphetamines 15. Alcohol/Drug
Opiates/analgesics

 

DR17) Which substance is your drug of choice, that is the drug that is your fitvorite?
(if) ..................................................

DR18) Would you consider yourself to be an alcoholic, a heavy or problem drinker, or having no

 

problems with drinking alcohol?

Alcoholic .............................................. 3
Heavy/Problem Drinker .................................... 2
No problems w/alcohol ..................................... 1

DR19) Would you consider yourself to be an addict, someone with a drug problem (but not an
addict), or someone with no problems with drugs?

Addict ................................................ 3

Drug problem ........................................... 2

N 0 problems w/drugs ...................................... l
DRl9a) Did you attend AA in the past 30 days?

No (CODE DR19B,C AS ”N";GO To DR19D) ....................... 0

Yes .................................................. 1
DR19b) If Yes, How many times in last month? ..................... _ Times
DR19c) If Yes, Do you consider yourself a member of AA?

Yes .................................................. 1

No .................................................. 0
DRl9d) Did you attend NA in the past 30 days?

No (CODE DR19E,F As ”N"; GO To DRZO) ........................ 0

Yes .................................................. l

DR19c) If Yes, How many times in the last month .................... _ Times
DRl9t) If Yes, Do you consider yourself a member of NA?

Yes ................................................. 1

No .................................................. 0

Since your last interview, how many times have you...

DR20) Had alcohol d. t. 's (NOT SHARES) .......................... _

DR21) Overdosed on drugs .................................. _

100

Since your last interview, how many times have you been treated for. . .

DR22) Alcohol Abuse (DO NOT INCLUDE AA) ......................

DR23) Drug Abuse (DO NOT INCLUDE NA) ........................

How many of these were for detox only? (IF RESPONSES ABOVE ARE ”0" , THEN PUT ”N" HERE)

DR24) Alcohol Abuse ......................................

DR25) Drug Abuse ........................................

How much would you say you spent during the past 30 days on. ..
DR26) Alcohol .......................................... $

DR27) Drugs (NOT PRESCRIPTIONS) ............................. $_
DR28) How many days have you been treated in an outpatient setting jbr alcohol or drugs
in the pasLfldays? (INCLUDE NA, AA) .......................... DAYS

DR29) How many days in the pastjadays have you equerienced alcohol
problems? ............................................. DAYS

DR30) How many days in the pasLiQdays have you experienced drug problems? DAYS
HAND PARTICIPANT CARD #1 - PATIENT RATING SCALE

DR31) How troubled or bothered have you been by these alcohol problems in the past 30 days?

Not at all (DR33 ”Can I asmme aleol. u isn't needed?') 1

Slightly 2
Moderately 3
Considerably 4
Extremely 5

DR32) How troubled or bothered have you been by these drug problems in the past 30 days?

Not at all (DR34 'Cen I assume drug in isn't needed?") 1

Slightly 2
Moderately 3
Considerably 4
Extremely 5

101

DR33) How important to you now is treatment jbr these alcohol problems ?

Not at all
Slightly
Moderately
Comiderably
Extremely

M&WNt—n

DR34) How important to you now is treatment for these drug problems?
Not at all

Slightly

Moderately

Considerably

Extremely

M13006)!—

Confidencefiatings: IS THE ABOVE INFORMATION SIGNIFICANTLY DISTORTED BY:

DR37) Patients's misrepresentation?
Yes (EXPLAIN) 1
N o 0

DR38) Patient's inability to understand?

Yes (EXPLAIN) 1
N o 0

Legal Status

 

Since your last interview, have you ever been arrested and charged with any of the following:

 

 

 

 

 

 

 

L803 Droplifling, vandalism L810 Arson
I L804 Forgeq L811 Robbery
I L805 Comenpt of court L812 Assault
I L806 Prostitution L813 Weapons (finse
L807 Parole/probation L814 Rape
violations
L808 Burglary, larceny, B & E L815 Homicide,
manslaughter

 

 

 

 

 

 

 

_ Ma:__s__ 1516 __

102

Have you been charged with the following since your last interview?
L818) Disorderly conduct, vagrancy, public intoxication TIMES
L819) Driving while intoxicated TIMES

L820) Major driving violations (reckless driving.
speeding, no license) TIMES

L824) Are you presently awaiting charges, trial or sentence ?

Yes 1
No (MARK "N" FOR NEXT QUESTION) 0

1.825) What fir? (IF MULTIPLE CHARGES, USE MOST SEVERE) ............

 

L826) How many days in the past 30 days were you detained or incarcerated? . _Days

L827) How many days in the past 30 days have you engaged in illegal activities for
profit? ................................................ Days

HAND PARTICIPANT CARD #1 - PATIENT RATING SCALE

L828) How serious do you feel your present legal problems are ? (EXCLUDE CIVIL PROBLEMS)

Not at all (L329 “Can I assume counselling not needed?") 1

Slightly 2
Moderately 3
Considerably 4
Extremely 5

L829) How important to you now is counseling or referral fior these legal problems?

Not at all 1
Slightly 2
Moderately 3
Considerably 4
Extremely 5

103
Confidencefiatings: IS THE ABOVE INFORMATION SIGNIFICANTLY DISTORTED BY:
L831) Patients's misrepresentation?
Yes (EXPLAIN) 1
No 0
L832) Patient's inability to understand?

Yes (EXPLAIN) 1
No 0

Family/Social Relationships

F801) Are you now: married, widowed, divorced, separated, or have you never been married?

Never married (including annulments)

Now married (including common-law marriages)
Separated

Divorced

Widowed

man"

F803) Are you satisfied with this situation ?
Yes

Indifferent

No

Ov—N

Do you live with anyone who
F808) Has a current alcohol problem
Yes 1
No 0
F809) Uses non-prescribed drugs ?

Yes 1
No 0

104

Have you had signyicant periods in which you have experienced seriouspmblems getting along
with?

 

 

 

 

 

 

 

 

 

 

 

NUMBER RELATIVE PAST 30 DAYS (Pm 'N" u: mum
HAVE CONTACT WITH PERSON)
F819 Mother
I F820 Father
F821 Brothers/Sisters
F822 Sexual partner/Spouse
F823 Children
F824 Other Significant family
F825 Close friends
F826 Neiggbors
F827 Co—Workers (MUST BE EMPLOYED OR
HAVE COWORKERS) g

 

 

 

How many days in the pasLjadays have you had serious conflicts. . .
F828) With your fizmily
F829) With other people (EXCLUDING FAMILY)

F830) How troubled or bothered have you been by these family problems in the past 30 days?

Not at all (F832 "Can I assume fam. counseling not needed?") 1

Slightly 2
Moderately 3
Considerably 4
Extremely 5

F831) How troubled or bothered have you been by these social problems in the past 30 days?

Not at all (F333 "Can I assume soc. pmb couns. not needed?") 1

Slightly 2
Moderately 3
Considerably 4
Extremely 5

105

F832) How important to you now is treatment or counseling firr these family problems?

Not at all 1
Slightly 2
Moderately 3
Considerably 4
Extremely 5

F833) How important to you now is treatment or counseling jbr these social problems?

Not at all 1
Slightly 2
Moderately 3
Considerably 4
Extremely 5
Confidencejatings: IS THE ABOVE INFORMATION SIGNIFICANTLY DISTORTED BY:
F835) Patients's misrepresentation?
Yes (EXPLAIN) I
N o 0
F836) Patient's inability to understand?
Yes (EXPLAIN) 1
No 0

Psychiatric Status

 

P801) Since your last interview, how many times have you been treated for any psychological or
emotional problems “hospital? (IF HOSPITALIZED, INCLUDE CURRENT STAY) TIMES

P802) Since your last interview, how many times have you been treated for any psychological or
emotional problems aLanoquatienLoLprivatepatient? ................ TIMES

106

Have you had a significant period, (that was not a direct result of drug/alcohol use), in which you

-.

Ergperienced serious depression

 

 

P805 Emerienced serious anxiety or tension
1 P806 Ergerienced hallucinations

P807 Experienced trouble understanding. concentrating
‘ or remembering

 

 

 

P808 Experienced trouble controlling violent behavior
(CAN BE DR UG—RELA TED)

P809 Experienced serious thoung of suicide (CAN BE
DRUG-RELATED)
If Yes, GIVE SAMI HELP CARD T0 PARIICIPAM

 

 

P810 Attempted suicide (CAN BE DRUG-REM TED)

 

PSll Been prescribed medication for any
psychological/emotional _problem

 

 

 

 

 

 

P812) How many days in the pastjadays have you experienced these psychological
or emotional problems? ..................................... DAYS

HAND PARTICIPANT CARD #1 - PATIENT RATING SCALE

P813) How much have you been troubled or bothered by these psychological or emotional
problems in the past 30?)

Not at all (P814 "Can I assume tx for psycho]. not needed?")
Slightly

Moderately

Considerably

Extremely

Uta-mu”

P814) How important to you now is treatment for these psychological problems?

Not at all
Slightly
Moderately
Considerably
Extremely

McbWNr—I

107
At the of the interview, is the patient: (JUDGE OVERT SYMPTOMS AND BEHAVIOR)

P815) Obviously depressed/withdrawn

Yes 1

No 0
P816) Obviously hostile

Yes 1

No 0
P817) Obviously anxious/nervous

Yes 1

No 0
P818) Having trouble with reality testing, thought disorders, paranoid thinking

Yes 1

N o 0
P819) Having trouble comprehending, concentrating, remembering

Yes 1

No 0
P820) Having suicidal thoughts

Yes (GIVE CRISIS CARD) 1

No 0

ConfidenceRatings: IS THE ABOVE INFORMATION SIGNIFICANTLY DISTORTED BY:

P822) Patients's misrepresentation?
Yes (EXPLAIN)
No 0

fl

P823) Patient's inability to understand?

Yes (EXPLAIN)
No 0

fl

APPENDIX B

APPENDIX B

1.115.“

I would like you to think about what your life will be like after you leave the hospital. I am going
to ask you about some different activities and I would like you to tell me if you think that you will
be doing them after you leave this hospital.

2. How likely do you think it is that you will be doing each of the jbllowing one year from now?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

‘ *PL03 Going to N A/AA meetings 2 3 4
PL04 Staying sober 2 3 4
PLOS Staying off street drugs 2 3 4
PL06 Going to treatment 2 3 4

(grow/individual therapy)
PLO7 Having a job 2 3 4
PL08 Having_a nice place to live 2 3 4
PL09 Having enough money to live on 2 3 4
*PLlO Managing your mental health 2 3 4
needs
PL11 Staying out of the hospital 2 3 4
(pmhiatric)
PL12 Getting aloanith your family 2 3 4
PL13 Havifl satisfying friendships 2 3 4
PL14 Getting a new gro_up of friends 2 3 4 I
PL15 Goig to school 2 3 4 I
PL 16 Doing volunteer for your 2 3 4 J
community or church

 

 

APPENDIX C

APPENDIX C

AAlNASelLHelpMeasure
DRl9a) Did you attend AA in the past 30 days?
No .......................................................... 0
Yes ......................................................... 1

DR19b) If Yes, How many times in last month?_ Times

DR19d) Did you attend NA in the past 30 days?
No ......................................................... 0
Yes ........................................................ 1
DR19c) If Yes, How many times in the last month_ Times

109

APPENDIX D

 

APPENDIX D

13..“ 1‘

Cluster 1:
Cluster one included persons who received a small amount of each service type.

Cluster 2:
Cluster two included persons who had some CMH services and some self-help services
and the most state and community hospitalizations.

Cluster 3:
Cluster three included persons who received no state hospitalizations, some community
hospitalizations, a good deal of CMH services, and the most self-help.

Cluster 4:

Cluster four included person who had no state hospitalizations, a small amount of
community hospitalizations and self-help, and the most CMH services.

110

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