Blending Perspectives and Building Common Ground. Promoting Client Retention and the Effectiveness of Services


Closely related to access and appropriateness of treatment are retention and effectiveness.  Substance abuse treatment has been found to be effective for many people in both the short and long terms as well as cost effective for taxpayers and society.  Outcomes for substance abuse treatment are closely linked to clients' length of stay and treatment completion.  Typically, the longer the client is in treatment, the better the outcomes.  Generally, few positive long term outcomes are seen unless the client is in treatment for at least three months (Hubbard et al, 1989).  Treatment may still be cost effective for shorter treatment episodes and for persons who do not maintain long term abstinence, (because of reduced crime, health care and other such costs while the person is in treatment and afterwards) but it is less likely that short stays produce long-term behavior change.

Effectiveness studies of substance abuse treatment programs consistently find positive outcomes, including reduced alcohol and other drug use, reduced criminal activity, improved health outcomes and improved employment and earnings.  For instance, the National Treatment Improvement Evaluation Study (NTIES), an examination of 4,400 clients who received treatment services in 1993-94 in programs funded at least in part by SAMHSA's Center for Substance Abuse Treatment, found that one-year post-treatment abstinence rates for 495 women seeking to regain or retain custody of children were highest for cocaine users (70-71 percent for powdered cocaine users and 52-62 percent for crack cocaine users) and were lowest for those who sought treatment primarily for alcohol problems (only 26-37 percent of these clients remained abstinent throughout the year after treatment).  Figure 7-2 shows one-year abstinence rates by treatment modality for female clients seeking to regain custody of children. 

Figure 7-2. Abstinence Rates One Year Post Substance Abuse Treatment for Female Clients Seeking to Regain Custody of Children by Treatment Modality, 1996.

Figure 7-3 shows this data by primary drug of abuse. 

Figure7-3. Abstinence Rates One Year post Substance Abuse Treatment for Female Clients Seeking to Regain Custody of Children by Primary Drug of Abuse, 1996.

Further, in addition to outcomes related to abstinence, women in these treatment programs showed improvements in other dimensions.  These included reduced crime and violence, increases in employment, and reduced mental health concerns.  For instance, among women seeking to regain child custody, the prevalence of prostitution declined from 54 percent in the year before substance abuse treatment to 17 percent in the year after treatment.  The study found that in this population, outcomes for outpatient treatment programs were generally similar to those for residential programs (Burgdorf, 1998).

Family and child custody outcomes appear to have improved for some NTIES clients following treatment, as shown in Table 7-A, although the relationship between treatment outcome and child custody outcomes was not strong.  Of female clients seeking to regain custody of children and remaining abstinent in the year post-treatment, 39 percent were living with more children after treatment than at admission.  Of female clients seeking to regain custody but who had negative outcomes, 26 percent were living with more children post-treatment.  Overall, 32 percent of the female clients who sought to regain custody of their children reported living with more children after treatment than before.  It seems likely that many of these were living with additional children because of successful reunification efforts (Burgdorf, 1998).

Table 7-A.
Relationship Between Substance Abuse Treatment Outcomes and Family Maintenance/Reconciliation Among NTIES Clients Who Entered Substance Abuse Treatment for Custody-Related Reasons, 1996


(row percent)
Clients seeking to regain custody
          Positive outcome (abstinent)
          Negative outcome (not abstinent)
          Positive outcome (abstinent)
          Negative outcome (not abstinent)









Clients seeking to retain custody
          Positive outcome (abstinent)
          Negative outcome (not abstinent)
          Positive outcome (abstinent)
          Negative outcome (not abstinent)









Source:  U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.  National Treatment Improvement Evaluation Study, (re-tabulations of 1996 study data by CSAT's National Evaluation Data Services).

NTIES clients who were motivated to enter substance abuse treatment by a desire to maintain custody of their children were more successful.  Of these clients, 51 percent of the male clients and 75 percent of the women reported no reduction, post-substance abuse treatment, in the number of children they were raising.  For male clients seeking to retain or regain custody there was essentially no relationship between treatment outcome and whether or not a client was living with their children.

Child welfare outcomes are rarely measured by substance abuse treatment programs, but early results from SAMHSA grantees operating substance abuse treatment programs targeting women with children report that 75 percent of their clients who successfully completed treatment remained drug free; 46 percent obtained employment following treatment; and 65 percent of clients' children in foster care were reunited with their families (HHS/SAMHSA, 1995).

Recently released findings from the Services Research Outcome Study (SROS), a five-year follow up of over 1,800 substance abuse treatment clients discharged from treatment in 1989-1990, show that substance abuse declined substantially in the five years after treatment (Figure 7-4).

Figure 7-4. Average Declines in Clients' Use of Selected Drugs at least 5 Times During the 5 Years Before and After Substance Abuse Treatment.

A minority of clients were abstinent, or nearly so, for a full five years after treatment.  Women consistently had greater declines in drug use than did men (Figure 7-5).

Figure 7-5. Declines in Clients'Use of Selected Illicit Drugs at Least 5 Times During the 5 Years Before and After Substance Abuse Treatment, by Gender.

The number of clients who reported having lost custody of children declined by 30 percent five years after treatment as compared with the five years before treatment (HHS/SAMHSA, 1998b), indicating that many had been reunited with absent children during this period.

A variety of individual evaluations of women's treatment programs have also found positive outcomes.  A study of PAR Village, a residential substance abuse treatment program for women and children in Florida, found positive outcomes such as reduced alcohol and drug use and reduced criminal behavior.  Success rates of over 80 percent were reported for those who completed treatment (Hughes, 1994).  A therapeutic community program in Arizona reports that 77 percent of treatment completers had at least one of their children living with them 6 to 12 months post treatment, as compared with 52 percent of treatment dropouts (Stevens and Arbiter, 1995).

While many treatment clients show improvements in a variety of areas, abstinence and other positive outcomes are not universal by any means, and improved outcomes are needed in several areas.  In particular, substance abuse treatment programs are known for high drop out rates that typically run upwards of 50 percent and may approach 80 percent in some instances.  A recent report from the U.S. General Accounting Office (USGAO, 1998) found that of substance abusing parents whose children have been in foster care at least one year in Illinois and California, most had either never entered substance abuse treatment (42 percent in Illinois and 40 percent in California) or had dropped out of treatment (34 percent in Illinois and 40 percent in California).  Fewer than 20 percent in each State had completed treatment or were currently enrolled in a treatment program (Figure 7-6). 

Figure 7-6. Treatment Status for Substance Abusing Parents of Children in Foster Care at Least One Year, 1997.

Along similar lines, Wobie and colleagues (1997) report a 38 percent completion rate for women entering a residential treatment program for mothers with infants.  Connecticut's Project SAFE reports that only 30 percent of clients assessed as needing treatment and referred to treatment programs actually enroll (Sheehan and Libby, 1998).  Zlotnick (1996) reports dropout rates ranging from 52 percent to 78 percent.  And Stranz and Welch (1995) report that 45 percent of their sample of mostly CPS-referred clients completed an intensive day treatment program for women with children - not ideal, but more than double the 21 percent completion rate for participants in a traditional outpatient program that served as their comparison group.  Famularo and colleagues (1989) found that 80 percent of parents failed to comply with substance abuse treatment ordered by courts in order to retain or regain child custody, and fewer than 10 percent of parents attended at least two-thirds of treatment sessions.  Clients addicted to alcohol and illicit drugs were equally non-compliant.  When looking at substance abuse treatment outcome studies it is important to understand the base group for whom outcomes are being reported.  Often outcomes are reported only for those who complete the full course of treatment.  Alternatively, data may be reported for all clients referred to treatment, even those who may have participated for as short a time as one day.

In large part because of such high drop out rates, the effectiveness of treatment is often challenged, particularly in the child welfare community.  In what are reasonably typical responses, an Ohio study found that substance abuse treatment was judged "not very effective" by more than half (53 percent) of child welfare caseworkers.  An additional 21 percent rated it as "somewhat effective," 14 percent said it was "adequate" and 12 percent thought treatment was "very effective" (The Public Child Services Association of Ohio, 1995).

Research suggests that providing child development, health care and other services to children of drug abusers promotes improved treatment outcomes for parents, including longer treatment stays (Stevens et al, 1989) and reduced frequency of relapse (Kumpfer, 1998).  The provision of child care has similarly been shown to improve treatment retention (Beckman and Amaro, 1986) and its lack has been shown to be a treatment barrier (Brown, 1992).  Studies of parent-oriented treatment programs also find improvements in family functioning.  Olsen (1995) found that a majority of mothers participating in a comprehensive, multi-agency collaborative treatment program made steady progress on goals related to substance abuse.  Families also showed improvements in housing, mental health, knowledge of child development and other related issues.  Magura and colleagues (1998), looking at intensive family treatment programs in New York City, found positive outcomes on many indicators, although not on foster care reunification rates.  Liddle and Dakof (1995) review the literature on the use of family therapy in drug treatment and conclude that several models of family intervention show promise as a means to engage and retain clients in treatment, reduce drug use and improve family functioning.  Research has also shown that parenting programs can improve parenting knowledge, attitudes, and practice of women with substance abuse problems (Camp and Finkelstein, 1997; Black et al, 1994).

Evaluations of programs funded in the early 1990s by the National Center on Child Abuse and Neglect to provide services to substance abusing families with child maltreatment issues documented a number of positive outcomes.  For instance, a number of projects were successful in getting parents to enter and remain in substance abuse treatment.  Some grantees achieved higher rates of treatment completion and longer periods of abstinence than had previously been attained.  Also reported were more effective discipline techniques among parents; better understanding of and response to meeting children's needs; more nurturing behaviors toward the children and less use of corporal punishment; and improved communications between parents and children.  Projects noted that while there were families who showed little or no progress, there were also many families who became committed to recovery and healthy parenting.  For these clients, programs became a lifeline and parents often became strongly attached both to project staff and to other clients who became a social support network to replace the unhealthy networks developed while immersed in the drug culture (HHS/NCCAN, 1995a).

In Illinois, Project SAFE and its successor, the Illinois Treatment Expansion Initiative, have for a number of years, worked hard to engage child welfare clients in substance abuse treatment services (USGAO, 1998).  Project staff have found that intensive, persistent outreach services are essential to engaging this client population in treatment.  Their efforts seem to have paid off.  Outcomes for initial clients included 81 percent treatment completion rates, with 51 percent of clients judged as having good or excellent prognosis.  More than half of clients' children in foster care (54 percent) had been reunified with their parents (White, 1995).  Others have also found that effective outreach is essential with this population (HHS/NCCAN, 1995b).

The experience of substance abuse treatment programs, particularly those geared towards parents and their children, demonstrates that many clients can and do improve their lives and many are able to resume their parenting roles.  Service providers have discovered repeatedly, however, that these clients are extremely difficult to engage and to retain in treatment programs.  However, programs geared specifically to the needs of women and their children and with highly trained outreach and treatment staff are more likely to get and keep women in treatment.  We must do a significantly better job in this regard if treatment progress is to be made within the time frames mandated by the Adoption and Safe Families Act.  Improving access to family services, psychological treatment, and other wrap-around services that have declined in recent years (Etheridge et al, 1995) may improve retention rates.  Closer collaboration with child welfare agencies may also be helpful in this regard.