Pathways of Substance Users Linking (Or Not) With Treatment

Abstract

This qualitative paper describes different pathways substance users experience as they decide whether to link to treatment or not after being assessed in a centralized intake unit in a Midwestern city. The narratives of 16 participants who did not link with treatment were compared with the narratives of 20 participants who did. Narratives from both groups described similar themes that were experienced differently. Nonlinkers were characterized by pretreatment abstinence, a negative experience with previous treatment, little previous engagement in a treatment career, and meaningful social support coming from AA. Linkers were more likely to continue using drugs before treatment entry, yet they described more readiness for treatment and were more engaged in a treatment career. The treatment careers approach provides a broader framework for understanding linkage versus nonlinkage to treatment.

Introduction

Addiction can be considered a chronic disorder characterized by multiple relapses and repeated treatment episodes (McLellan, 2002; McLellan, Lewis, O'Brien, & Kleber, 2000). Over time, multiple treatment episodes merge and become treatment careers (Hser, Anglin, Grella, Longshore, & Prendergast, 1997; Anglin, Hser, & Grella, 1997). The treatment career is marked by critical transition points like treatment seeking, treatment linkage, engagement, treatment exit, and reentry. This career perspective allows treatment to be evaluated in new ways by situating individuals within a particular stage of the relapse-treatment-recovery cycle (Scott, Foss, & Dennis, 2005; Dennis, Scott, Funk, & Foss, 2005).

When considering a single treatment episode, reasons for and against linking with treatment have been attributed to demographic characteristics, health and substance abuse factors; intra-psychic factors (problem recognition, psychological distress); social factors (negative social consequences, interpersonal pressure, legal coercion); life events, and prior treatment experience (Tsogia, Copello, & Orford, 2001). However, it remains difficult to predict accurately who will enter treatment and when. During multiple treatment episodes—or treatment careers—the individual's decision to link (or not) to treatment is also understood in relation to the individual's current position in the relapse-treatment-recovery cycle.

Studies of treatment outcomes generally focus on the evaluation of a single treatment episode by examining outcomes of a year or less (McLellan et al., 1994; Hubbard, Craddock, Flynn, Anderson, & Etheridge, 1997). Although single episodes of treatment are consistently associated with positive outcomes, it is likely that substance abuse treatment effects are cumulative across multiple treatment episodes. That is, the stable cessation of substance use may be observable only in the long term and within the context of an individual's life course (Hser, Stark, Paredes, Huang, Anglin, & Rawson, 2006; Termorshuizen, Krol, Prins, & van Ameijden, 2005).

The Persistent Effects of Treatment Studies (PETS) initiative examined longer outcome data (30 months or more) and developed a fuller understanding of the dynamic relationship between episodes of substance abuse treatment and related behaviors over time (McKay & Weiss, 2001). For instance, Dennis and colleagues (2005) conducted survival analyses to estimate the time from first use and first treatment until substance users reported 12 months of abstinence or died. During the three years after intake, 47% reached at least 12 months of abstinence. The median time from first to last use was 27 years. The median time from first treatment episode to last use was nine years. Years to recovery were significantly longer for males, people starting use under the age of 21 (particularly those starting under the age of 15), people who had participated in treatment three or more times, and for people high in mental distress.

Another PETS study identified different pathways in the relapse-treatment-recovery cycle indicating that the effect of an index treatment episode is largely mediated by initial response to treatment, participation in aftercare and 12-step support groups (Scott et al., 2005; Scott, Foss, & Dennis, 2003). These pathways have also differed by gender, with women having more episodes of subsequent treatment and men showing higher rates of incarceration (Grella, Scott, Foss, Joshi, & Hser, 2003). Kissin and colleagues' (2003) PETS study investigated different patterns of self-help attendance in relation to levels of substance use over a period of 30 months and found that continuous self-help participation was associated with reduced use. Finally, higher self-efficacy during follow-up was associated with lower perceived seriousness of substance use, whereas greater self-help attendance was associated with greater perceived seriousness of substance use (McKay et al., 2005).

Although the treatment careers approach has received increasing attention as a broader framework for understanding and describing what motivates substance users to link or not with treatment, the perspectives that substance users themselves have remains largely ignored (Carlson, 2006; Tsogia et al., 2001). Ethnographic studies examining the process of treatment linkage have largely focused on barriers to treatment. Treatment barriers perceived by substance users have been related to waiting time (Redko, Rapp, & Carlson, 2006), availability of treatment slots (Wenger & Rosenbaum, 1994), social stigma and labeling (McMurphy, Shea, Switzer, & Turner, 2006; Copeland, 1997), fear of punitive actions like loss of child custody (Jessup, Humphreys, Brindis, & Lee, 2003), fear of treatment (MacMaster, 2005), and cultural and personal barriers like difficulty in speaking in English or lack of readiness (Porter, 1999).

Koester and colleagues (1999) introduced a different dimension to the ethnographic description of treatment linkage in lieu of discussing treatment barriers. They described what motivated substance users to enter treatment since they sometimes seek treatment for reasons other than complete abstinence. In a similar vein, Hartwell (1998) found that what motivated chronic recidivists to repeatedly link to substance abuse treatment was not related to abstinence but rather responded to more immediate needs. This study will contribute to the discussion of treatment linkage by using qualitative methods to compare the different pathways that led 20 substance users to link with treatment with 16 substance users who did not link with treatment. These pathways are most effectively understood from a life course and treatment career perspective since problematic patterns of substance use have multiple entry and exit points (DiClemente, 2006).

Methods

This paper is based on qualitative interviews and survey data collected as part of the Reducing Barriers to Drug Abuse Treatment Services Project (RBP), a five-year study funded by the National Institute on Drug Abuse. The RBP is a three arm clinical trial designed to assess the effectiveness of strengths-based case management and motivational interviewing, relative to a standard referral process, in linking clients with treatment services and subsequently engaging them in services. Eligible subjects were (a) over 18 years of age, (b) diagnosed as having a substance abuse and/ or dependence disorder using criteria from the Diagnostic and Statistical Manual (DSM-IV-TR™) (American Psychiatric Association, 2000), (c) not suffering from schizophrenia or any other psychotic disorder, and (d) referred to either residential or outpatient substance abuse services. Alcohol abusing or dependent individuals without other substance disorders were not eligible.

The RBP is located in a centralized intake unit (CIU) in Dayton, Ohio, with a county population of 552,000 (U.S. Census Bureau, 2003) The CIU is the county's only point of entry for uninsured individuals seeking treatment for substance abuse and mental health problems. Assessment therapists conduct psychosocial, mental health, and substance abuse assessments to determine the nature and extent of clients' problems. Clients are referred to an appropriate level of care within the community treatment system based on American Society for Addiction Medicine criteria (American Society of Addiction Medicine, 2001) and situational factors such as treatment availability and client preference. Referrals are made to eight state-certified, specialty substance abuse treatment programs. Clients generally do not contact the treatment program immediately after the assessment, but must wait several days before learning of their treatment admission date. After 90 days of the initial CIU assessment, if clients have not yet entered treatment, they must be reassessed as dictated by state administrative rules.

Upon entry into the study, clients signed a release authorizing research staff to review their clinical records at any treatment program that they entered. Linkage was verified by reviewing the clinical records at the treatment program to which clients were referred. If participants did not link with the program to which they were referred by the CIU, other programs were queried to see if the subject had linked at that program instead. If confirmation of attendance could not be made at any of the treatment programs, the subject was coded as a nonlinker. Linkage to treatment was defined as meeting with a counselor for the first clinical contact whether in the form of individual, group, or family counseling. Administrative (prelinkage) contacts spent filling out releases and admission information were not counted as clinical contacts.

The first author selected a diversified convenience sample from the clinical trial population served by the CIU considering variables like gender, ethnicity, age, and primary substance used. Each participant responded to two audiotape recorded interviews averaging 90 minutes each (baseline and three months) conducted by the lead author at the CIU. The baseline interview protocol covered history of substance use, abstinence and help-seeking attempts, history of substance abuse treatment, barriers to treatment, treatment engagement, and interactions with health services and study interventions. The three-month interview also focused on whether participants had linked or not with treatment and details of these experiences. Qualitative interviews took place in a private office at the CIU between May 2004 and February 2005. Individuals were compensated $20 for their time. Participants completed an informed consent form approved by the University's Institutional Review Board.

Ethnographic interview audiotapes were transcribed verbatim and analyzed by the project ethnographer using NVivo®, a program designed for qualitative data analysis (Richards, 1999). Initially, the narratives of each participant were summarized by identifying the emerging themes related to experiences of linking with treatment (or not). Afterwards, the different narratives were clustered together whenever it was suspected that correlations between themes would be better understood in relation to a major attribute (Turner & Bruner, 1986). For instance, narratives of those substance users already engaged in a treatment career were contrasted those who had none or very little treatment experience. This was done to examine whether previous treatment experience influenced participants' attitudes and concerns regarding linkage to the index treatment. Throughout this article narrative excerpts of substance users are provided under fictitious names to protect the anonymity of research participants.

Results

Characteristics of Study Participants

Twenty-four men (66.7%) and 12 women (33.3%) who were assessed for substance abuse treatment at the CIU agreed to be interviewed immediately following their assessment and then again three months later. Twenty subjects (55.6%) were categorized as linkers because they had, according to the clinical records of treatment programs, linked with treatment within 90 days of the CIU assessment. The remaining sixteen (44.4%) nonlinkers had not entered treatment within 90 days, although three of them did eventually link after 90 days.

Regarding drug of choice, 23 (63.9%) participants preferred to use crack or powdered cocaine, 11 (30.6%) used heroin and/or pharmaceutical opioids, and the remaining two (5.5%) had a preference for marijuana. Combining drug of choice with linkage rate, eight (72.7%) heroin users linked with treatment, 23 (52.2%) crack-cocaine users linked, while both marijuana users did not link. A total of 11 (30.5%) participants were referred to residential treatment, 21 (58.4%) participants were referred to outpatient treatment, and the remaining four (11.1%) participants were referred to a methadone program. Seven (63.6%) participants who were referred to residential treatment linked, nine (42.8%) who were referred to outpatient treatment linked, while all four (100%) participants who were referred to a methadone program linked. Not all heroin/opiates users were referred to a methadone program. The majority of the participants (69.4%) had previously been in some form of substance abuse treatment. Of those, nine (25%) had been to treatment once, and 16 (44.4%) had multiple treatment episodes. Eleven (30.6%) had no previous treatment experience.

Twenty of the 36 study participants were White (55.6%), 15 were African American (41.7%), and one participant was Native American (2.7%). Fourteen participants (38.9%) had completed high school or had a GED, while 12 (33.3%) had some college education. The remaining 10 (27.8%) had less than a high school education. Of all participants, 13 (36.1%) were court ordered to link with treatment, but only 10 court ordered participants linked. Over half of the participants (52.8%) were unemployed during the six months prior to the assessment. The average age was 39 (SD= 10.9), and nine (25%) were 30 years old or less. At the time of assessment more than half (52.8%) of participants were living with family or relatives, 11 participants (30.6%) were homeless, five participants (13.9%) were living with a group of friends, and one participant (2.8%) lived alone.

Since Alcoholics Anonymous (AA) meetings are more ubiquitous than NA, these participants had more opportunities to attend AA. Twenty-nine participants (80.6%) had attended Alcoholics Anonymous (AA) in their lifetime, and 23 (64%) had attended more than 10 meetings. During the three months immediately after the CIU assessment, 21 (58.3%) participants had attended AA. Of these, twelve felt that AA was always helpful. During this same three month period, one third (seven) of the participants attended 10 meetings or less, another third attended between 11 and 25 meetings, and the remaining third attended between 26 and 100 meetings. Regarding linkage status, 12 linkers and nine nonlinkers did attend AA during the same period.

Participants' narratives conveyed five major themes related to experiences of linking with treatment: readiness for treatment, reaching abstinence, barriers related to treatment programs, previous treatment experiences, and the social support found in self-help programs. We will describe below how each of these issues were perceived and experienced differently by those who linked and those who had not.

Treatment Seeking Around Time of Assessment: The Issue of Readiness

Showing up for a substance abuse assessment and receiving a referral were the first steps taken by participants in order to link with treatment. All 36 participants recognized they needed some kind of treatment when they answered the baseline quantitative survey “If you had a choice, what kind of treatment would be best for you now?” Around the time of assessment, participants were also interviewed by the ethnographer. During this first encounter several participants disclosed their readiness to treatment to the ethnographer.

Comparing the narratives of those who linked to treatment within 90 days with the narratives of those who did not link, the linkers spontaneously expressed their readiness to treatment. Matt, a 46-year-old White man who abused heroin and was court ordered to treatment said, “I am ready for it [treatment]. I am going to do it because I have to, and it is going to help me anyway. It will assist me after all, the group sessions and all that stuff. It strengthens you!” Karl, a 45 year old African-American man who abused crack commented: “I am ready to go get some help. When I am ready it is just like listening to all the positive things.” Both Matt and Karl linked with treatment and had previous treatment experiences.

Readiness was also expressed in terms of being sick and tired, or hitting rock bottom. Louise, a 40 year old African-American woman who abused crack explained, “I'm just tired, I'm sick and tired of being tired. I'm ready to get this right today. I'm ready to get my life together.” Louise linked with treatment only after 90 days because during the treatment seeking process she found a job and slipped to crack use a few times.

When the nonlinkers talked about readiness, they consistently referred to occasions when they were ready in the past, rarely in the present, or they commented about the importance of being ready. Some nonlinkers expressed their lack of readiness during the first interview: Rick, a 49-year-old African-American man who smoked crack said: “I am not really ready to give it up because I enjoy smoking dope.” Elvis, a 54-year-old African-American man who injected heroin and had five previous treatment experiences said: “I have a brother who would tell me, ‘why don't you go to treatment?’ [I responded] I'll go when I get ready.”

Although participants were in the process of linking with treatment, a few mentioned that reasons for wanting treatment were not always related to stopping drugs or recovery. Some participants who were court-ordered to treatment reasoned that going to treatment was better than jail. A few women were forced into treatment because Children Services threatened to take their children away. Other participants had other motivations for the CIU assessment, like taking care of mental health problems, being assessed to gain disability status, maintaining a driver's license, and keeping a job. In some situations, individuals just wanted some time off from the “street life” and the drug addict lifestyle.

Pretreatment Abstinence

Linkers differed significantly from nonlinkers in their substance use practices before linking with treatment. It was very common for linkers to continue drug use while they waited to link with treatment. Carla, a 39-year-old woman who abused tranquilizers and alcohol and went to treatment twice said: “I just drank, went to the bars and drank and got back and go to sleep. That's how I waited until I got in there [treatment].” Ned, a 53-year-old African-American man, a poly-substance abuser who was a court-ordered to treatment explained, “I'm still having to use drugs because I'm getting sick every day, and it's been over two weeks. I don't like this waiting.”

Some linkers tried to control use, substitute drugs, or reduce use while they were waiting for treatment. Ralph, a 50-year-old African-American man who had seizures, smoked crack, and was court-ordered to treatment said: “I tried it [crack] once since I been out of jail; it's just time. I'm going to do all I can to get away from drugs.” Jason, a 36-year-old White man who injected heroin and cocaine, finally decided to link with treatment (after 90 days) because of a binge, which happened soon after he relapsed from 84 days of abstinence. After being reassessed, he tried to control and reduce drug use while waiting for residential treatment: “During the five weeks of wait, I slowed way down ‘cause I didn't want be dope sick when I came to treatment. But my last week out there, I didn't use until the night before I came in. I did one last shot.” Like Jason, those participants who were dependent on heroin, usually had a difficult time maintaining abstinence before treatment.

Other linkers have tried to “stay clean” while waiting for treatment, but most ended up slipping or relapsing before treatment entry. Thomas, a 33-year-old White man who smoked crack tried very hard to stay clean because of his prolonged probation after nine years in prison. When he violated probation because of a four day crack binge, he was court ordered to treatment. Thomas stated: “I smoked once or twice and then put it down. This last time, this last week I smoked and it just kept going and going and going. I wanted to, you know, absolutely die, so self-destructive.” Fabian, a 34-year-old White man described a repetitive cycle of going to treatment four times, attending AA, substituting crack for alcohol binges, returning to treatment again, more crack binges, and so forth. He said “It's kind of monotonous, I'm tired of doing it, I either need to stay clean and do what I need to do, or I need to stay out on the street [using drugs].”

Only two linkers were already abstinent before treatment entry. Joshua, a 34-year-old White man who smoked crack and had no previous treatment experience, maintained abstinence before treatment linkage with the craft of making key chains that he would give away to people: “I found another way to go about it [making key chains] rather than getting high, and that's a high for me.” Matt, a White man who snorted OxyContin®, heroin, and cocaine didn't believe he had “a serious problem” with drugs because he stopped using on his own, yet he was court ordered to treatment: “I'm on probation; they referred me to this [assessment], which I don't mind. I'm not that addicted.”

Among the nonlinkers, pretreatment abstinence was the strongest reason for not linking with treatment. As Elvis explained: “I had been clean for so long [almost three months] that I feel that I didn't need outpatient.” Jason, again, a 36-year-old White man who injected heroin and cocaine, worked as a carpenter, and went to treatment three times before, said “so I lasted 84 days clean.” Since Jason was waiting for so long, his life situation changed, which made him relapse. John, a 45-year-old African American who abused crack and alcohol and had no previous treatment experience was proud that “I kicked the habit and it feels good to be drug free. I did this all by myself. No sense in me going [to treatment] if I can just keep a clear mind and a steady head. I can do these things. So that's what I did.”

System Factors Influencing Linkage

Both linkers and nonlinkers described a whole series of treatment system factors that influenced linkage, yet both made more reference to how system factors negatively affected linkage. In this context, the stories of Lilian and Julia are informative.

Lilian, a 19-year-old White woman who abused heroin managed to link with treatment in spite of several system factors. Lilian was court ordered to treatment because she prostituted herself to support her heroin addiction. She returned to live with her parents for family support and to facilitate linkage with treatment. Her mother was even helping her buy heroin every day, so she would not feel “dope sick” while waiting for treatment. Lilian was very critical of the CIU assessment and refused the referral to the methadone residential program because she was completely against taking methadone. She was then referred to another residential treatment program, but before entering the program she had to go to the hospital for detoxification. As Lilian asserted, “CIU is my barrier. These people throwing me around, insurance, and my probation officer, they all just be saying different stuff, and I just want help; why can't I get help? It's frustrating me.”

After being released from detoxification, it was 10 days before Lilian entered the residential program. She relapsed during that time, and for this reason walked out of the residential treatment the day after she entered. Since Lilian walked out of treatment, the probation officer made her go to jail for 60 days. While in jail she participated in weekly AA meetings. After completing time in jail, Lilian went to visit her sister in another state and upon return she relapsed.

More than 90 days had passed so Lilian did another CIU assessment, and this time she was referred to yet another outpatient program. But at this program she was referred to the residential portion of the program with the condition of first going through detoxification in another outpatient program. After a period of detoxification with methadone, Lilian would be allowed to attend the residential program. Lilian maintained abstinence since she started taking methadone. She said: “I am sober as can be and it sucks, deal with the real world, and it sucks!” She also began occupying her time with a fast food job and with church volunteer work. She was also appreciating the counseling services provided by the detoxification program and did not want to be transferred to the residential program anymore.

A different example is presented by Julia, a 35-year-old White woman who smoked crack and who did not link to treatment largely because of structural barriers that created rules and regulations she believed were inflexible. She returned to her home town to get “clean” from drugs and to escape from the drug abusing environment she was living in. Her family was providing emotional support because Julia was trying to link with treatment for the first time. She started a diary because she loved to write; it was her way of coping with the waiting time until treatment entry. After the CIU assessment Julia received a referral to residential treatment. She mentioned that having no health insurance, no money, and no job were not considered treatment barriers by her or her family because “we found ways around them.”

During the follow-up interview Julia had not yet linked to treatment. She said: “I'm experiencing some depression. A little over four months clean now. Because I got that job, I still have had no treatment at all. It's very frustrating for me to have come this far really, largely by my own efforts and without any help at all. I've also had some AA meetings.” When she went to the orientation session of a residential treatment, the counselor recommended a level of care change to the outpatient sector of the same treatment program because of Julia's high educational level. She found the outpatient program unresponsive to her needs because they communicated only after two months of persistent phone calls.

In the meantime she began a part-time job as a waitress which caused problems: “Explain to me why the system would punish someone who had managed to get well enough to go and get employed, to deny them treatment because they're working.” Julia was very angry because the outpatient program required that she complete four weeks in her waitress job to provide the pay stubs that would qualify her into a specific treatment fee scale: “The time the person needs the help is when they are asking for it. They need it immediately.”

When it came time to start outpatient treatment, more than 90 days had passed. For this reason Julia had to redo the CIU assessment and was referred to another treatment program. During this new waiting period she quit her job and stopped going to weekly AA meetings. Soon afterwards she ran away from her family's home and probably went to live with her boyfriend again, who also had addiction problems.

Both Julia and Lilian had to redo the CIU assessment because the treatment programs they were initially referred to in some way or another did not correspond to their needs. Needing a level of care change usually slows down (if not stops) the process of treatment entry. Another system factor influencing treatment linkage is the quality of the initial interactions that substance abusers have with treatment staff. For example, Daniel, a 45-year-old African-American man who smoked crack and had no previous treatment experience, gave up going to treatment during the initial orientation sessions. He explained that counselors did not treat him as a person and did not listen to him because they believed he was in denial. Daniel reported: “She said that I was in denial, and I was going to have a big problem because I wasn't willing to admit the fact that I had a drug problem. It [the counselor] went on to list things that she thought.” Later he suggested that counselors should “build up my strengths, don't harp on my weaknesses.” Allan, a 27-year-old White man who smoked marijuana and snorted cocaine did not link because he walked out of the residential treatment on the first day: “I was treated like a criminal in there, but then when they ran it like the Nazis, that's exactly how I felt.” The quality of the relationship with the treatment staff seemed to be one of the most important system factors that affected linkage.

Treatment Career

In this study sample, linkage to treatment was related to previous treatment experiences. Among 20 participants who linked to treatment, only four individuals had no prior treatment experiences. In contrast, nonlinkers were almost equally divided between those with previous treatment experience (nine) and no treatment experience (seven). For this reason we investigated how participants perceived their previous treatment experience.

When linkers talked about previous treatment experiences they were more likely to recall positive treatment experiences, than negative ones. Ted, a 51-year-old White man who had been to methadone programs eight times still believed in treatment: “If you give methadone a chance, it will work. I do believe, it's worked for me before, but you got to give it a chance.”

The most common positive experience mentioned by linkers was the possibility to talk about their problems during treatment. For instance, Erasmus, a 46-year-old African American man who used crack, commented that he appreciated going to outpatient treatment three times a week because “Being able to run my mouth. I am a talker, I love to talk.” Later Erasmus commented that treatment should be much longer to be efficacious: “Twenty-eight days is not going do nothing for me. In that case give me six months in the treatment center.”

Other positive experiences included feeling good about oneself and being able to relate to the situation of other drug users. Lara, a 39-year-old White woman who smoked crack commented that she had a positive experience with treatment because “I was just real excited about meeting new people [in the treatment program] and about learning stuff about myself, about what is going on with me.” Holly, a 64-year-old African-American woman who smoked crack explained that “people are talking about their problems [in group sessions] and you sit back and say, I've been there, I've done that.”

The nonlinkers did not emphasize positive treatment experiences, even though they eventually recalled them. When the nonlinkers talked about past treatment they often mentioned a negative experience that helped them justify not linking with treatment in the present. For instance, Steve, a 42-year-old Native-American nonlinker who smoked crack said “they wanted to send me to program A, and I've already been involved with that program before. I don't like the format!” Rick, a 49-year-old African-American man who smoked crack explained that he did not link because “fear of leaving rehab, more scary than anything.” It is very hard to return to the community after living in the protective environment of a residential program. Dale, a 44-year-old African-American man who smoked crack said that he has been in treatment 12 times, however: “I never completed a program in my entire life, whether I relapsed or not.”

The common criticism that nonlinkers raised about treatment programs was that they can be repetitious. Dale commented: “I'm not going to say nothing clicked, but I keep hearing the same information over and over again.” Elvis questioned the need for treatment, stating: “I know as much as the counselor. Some head counselors have never even used drugs; I've been on both sides of it so I don't feel like I need to be in treatment. I would get bored with it early.” Later, Elvis complained that all five treatment programs he attended followed a similar approach: “Every treatment program that you go though is basically the same pattern, the same thing over and over, it is the same procedure, it might be different weeks, but it's the same things, you see the same movies.”

Three of the nonlinkers ended up linking after 90 days. Two of them found some benefit in repetition: Louise, a 40-year-old African-American woman who smoked crack and had been in treatment four times, explained: “Treatment gives you what they tell about drugs, [to] always rewind that tape when I was on drugs. If I use again it rewinds that tape before I pick up again. It is strengthening and helping me.” Mark, a 25-year-old White man who abused marijuana and cocaine, concluded: “This is my third time. I've been in treatment before now. It is good that I hear these things again because evidentially the first time I wasn't listening because I ended up picking up again. So I can't say it is not a good thing to hear.”

Self-Help Groups and Treatment Linkage

Participation in self-help groups influenced treatment linkage in varied ways. Some linkers commented that they preferred to go to treatment than to a self-help group because they perceived self-help in negative ways or had negative experiences with it in the past. Beatrice, a 44-year-old African-American woman who smoked crack explained she did not like AA because it triggered the urge to leave the meetings to go use more drugs. She said: “Most people come in AA they're talking about the drugs. How it made them feel, this and that, and I was still smoking and I got out of there it just made me say go get some.” Erasmus, a 46-year-old African-American man who smoked crack and had three previous treatment experiences, refused to go to AA: “I have nothing against going to meetings but in my mind that's addictive too. Because now you're telling me I need this meeting to stay sober, I'm dependent. That's an addiction within itself.” Karina, a 24-year-old White woman who used heroin, had also a very negative opinion of AA. She said “I hate 12 step programs. They just-they do not work for me. I don't know. I think it's a bunch of rhetoric propaganda, basically. It's brain washing bullshit.” Most other linkers also had the opportunity of attending AA while in treatment or as part of aftercare, and they generally stated no preference between self-help groups and treatment.

Some participants did not link with treatment because they were able to maintain abstinence while waiting, and they did so with the help of AA. Mark, a 25-year-old White man who used marijuana and cocaine and had a previous treatment experience stated, “It would be useless not to try AA because I really want help. I haven't picked up in 13 days. I go to a meeting every day, I try to at least. My work it interrupts, but there's always a meeting you can go to no matter what time.” Julia, a 35-year-old White woman who smoked crack, was influenced by an uncle who has been active in AA for more than 20 years. She managed to stay sober while waiting for treatment with the help of AA, stating, “It's largely helpful because you learn vicariously through other people's experiences, somebody who struggles with a problem which maybe isn't the same substance, the same core problem, you can still draw experience and wisdom through.” Although Mark and Julia did not link with treatment, they perceived AA participation as an important first step while waiting for treatment.

Some nonlinkers, tried to stop on their own, and when that did not work, they sought the help of 12 step programs. Dale, a 44-year-old African-American man who smoked crack, had already gone to treatment more than 12 times. He said, “I was trying it by myself, I couldn't, then I started going to AA meetings, where people just like myself existed, I never thought existed. One thing about AA people they never say I don't understand because they understand, they can identify and they empathize.”

Some nonlinkers started going to AA because of probation. Randall, a 22-year-old White man who injected heroin, attended AA soon after leaving jail saying: “There's no doubt in my mind. I honestly believe if it wasn't for AA and the step that I'm working, I've already went back out and used.” Initially, Randall was not sure whether AA would be helpful, but waiting for treatment was so disappointing that “I was doing ok with AA, so I just stuck with AA.”

Few nonlinkers attended AA and had a negative perception of it. Jason, a 36-year-old White man who used heroin, attended AA twice a week while waiting for treatment. He stated, “I think AA bores me. I just can't, I don't drink, and I can't relate.” Daniel, a 45-year-old African-American man who smoked crack, commented that going to meetings triggered the need of doing drugs again: “Every time I went to a meeting I had to do drugs. I left, I wanted to do some drugs, because you heard these stupid, lying stories.”

In some circumstances self-help groups played a positive role, other times a negative one, in relation to influencing participants to link with treatment or not. Functioning as a resource of social support was the major characteristic of AA that attracted many participants, whether they linked or not. For instance, Fabian, a 34-year-old White man who alternated between crack binges and temporary jobs said: “I have somebody to run around with. I am running around with some people in AA. Just going to meetings was giving me a more positive outlook. Just being around people that were not using drugs.” Thomas, a 33-year-old White man who smoked crack, commented: “I like AA. I'm getting that network of support. I had a network on the other side, when I was using, I had a network of people to do bad things. So why not have a network of good things?”

Discussion

Treatment seeking substance users, both those who linked and did not link with treatment, identified similar themes in their narratives. Although similar, these themes were perceived in different ways. Members of both groups talked about abstinence (or continued drug use), system factors affecting linkage, employment, their previous experiences with treatment, and the role of social support offered by self-help groups. Their narratives often alluded to a constant cycle of relapse-treatment-recovery associated with the treatment career perspective.

Abstinence, or continued drug use, was the most consistent theme that appeared in the narratives. This was not entirely surprising since the main topic of treatment is abstinence from substance use. Substance abusers who made the decision to not link with treatment were likely to stop using on their own before CIU assessment or treatment entry, while linkers commonly continued to use until their admission to treatment. The difference between those who stopped using on their own from the treatment seekers who only stopped with the help of treatment is not so dramatic when the treatment career perspective is taken into account (DiClemente, 2006). The subjects who said they had stopped using without treatment may go on to self-recovery (Sobell, Ellingstad, & Sobell, 2000). But we still need to analyze the six month follow-up data in order to have a better idea of the extent of time that nonlinkers were able to remain abstinent. From the three month data we know that a few nonlinkers did not stay abstinent for very long, and some became treatment seekers once more. In short, the self-changer of today might become the treatment seeker of tomorrow.

Nonlinkers often perceived their ability to stay abstinent as proof that they did not need treatment anymore. Linkers cited perceived “readiness” and a difficulty in sustaining abstinence as their reasons for deciding to enter treatment. Some linkers were unable to stay sober, while others did not even attempt sobriety because of their intention of linking with treatment. It is also noteworthy that those participants who were heavy heroin users had more difficulties in sustaining abstinence before treatment entry. Opiate users (72.7%) were more likely to enter treatment than crack cocaine users (52.2%), but not all opiate users attended a methadone program. This may have occurred for several reasons. In some instances clients believed that methadone was too addictive. Waiting lists and rules governing methadone dosage may have also been a barrier to treatment entry.

Independent of linking with treatment (or not), participants indicated that several system factors had the potential to interfere with their readiness for treatment. The most frequent system factors mentioned were waiting time, dissatisfaction with treatment referral, and the quality of relationship with treatment staff. Apparently, linkers went to treatment in spite of the system factors encountered, while the nonlinkers perceived these system factors as barriers that kept them from entering treatment. It is noteworthy that they did not describe system factors in a positive way, although some mentioned positive treatment experiences.

Other circumstances not directly related to system factors interacted with waiting time and influenced treatment linkage as well. The most prominent was employment. For instance, some participants found that finding a job while waiting to enter treatment became a barrier to treatment linkage instead of enhancing it. Participants also referred to social support, most specifically participation in self-help groups, as the other driving force to overcome their addiction. Participation in self-help groups either enhanced linkage or happened in place of treatment linkage. Even so, only a few participants described an intense involvement with AA that included working the steps, relationship with a sponsor, and helping others. Moos and Moos (2005) have demonstrated that individuals who participated in both treatment and AA were more likely to achieve remission than those who participated only in treatment or only in AA.

The majority of participants had at least one previous treatment experience. By comparing the narratives, it became evident that nonlinkers were prone to emphasize negative experiences with treatment in the past. Linkers were more likely to recall positive experiences with treatment. In other words, linkers often framed their narratives about previous treatment engagement in a manner that encouraged them to link to treatment. Quantitative studies have also indicated that linkers usually report a successful experience with treatment in the past (Hser, Maglione, Polinsky, & Anglin, 1998).

Research focusing on treatment careers has evaluated the dynamic relationship between substance use, treatment episodes, and related behaviors over time (Scott et al., 2005; McKay et al., 2005; Dennis et al., 2005). For instance, understanding how individuals transition from being in the community using, being in treatment, or being in the community not using, can be helpful to develop interventions that shorten the cycle between relapse, treatment, and recovery (Carlson, 2006). Besides, these career studies have suggested that rather than thinking of multiple episodes of treatment in terms of “cumulative dosage,” they represent further evidence of chronicity. Interventions with a longer term recovery management become necessary in this context (Dennis, Scott, & Funk, 2003).

Most study participants had previous treatment experiences; they were already engaged in a treatment career (Anglin et al., 1997; Hser et al., 1997; Siegal, Falck, Wang, & Carlson, 2002). Particularly those participants who had previous treatment experiences perceived treatment as a prolonged process encompassing successes and failures, rather than a single time success. That may be why studies that investigate predictors of a single treatment linkage episode remain inconclusive (Tsogia et al., 2001). Study participants, particularly the linkers, perceived treatment as a process that developed numerous transitions towards recovery. They often believed that each previous treatment experience contributed to the current decision to link with treatment again. Apparently what really mattered for treatment repeaters was the persistence of going to treatment over and over again.

The repetitive character of substance abuse treatment was frequently noted in two different ways. In some cases, participants complained of doing the same activities over and over again. In other cases they referred to going into treatment multiple times. Several participants acknowledged that a single treatment episode was not sufficient to deal with their addiction. Nonlinkers tended to criticize this repetition while linkers frequently believed they could benefit from it. Repeating treatment again strengthened some linkers to reestablish sobriety.

It remains unclear whether multiple treatment episodes (repetition) or a longer treatment period would be more efficacious. This also raises questions about how much time is enough to complete treatment and how treatment programs should balance innovation and repetition of practices and content to attract and be more effective to a broader clientele.

Limitations to this study include a small convenience sample of treatment seeking substance users selected from a larger randomized controlled trial comparing two pretreatment interventions. Findings largely reflected participants' experiences and self-reports; yet some individuals might have had inaccurate recall of events, for instance, when they described details of previous treatment experiences. However, self-report data from studies of drug users tend to be reasonably reliable (Adair, Craddock, & Turner, 1995; Needle et al., 1995). Another limitation is related to the short period covered in relation to the time frame of treatment careers still in development. Study participants were at different points in their treatment careers, instead of all being followed from the very first time they were seeking treatment. In addition, participants were interviewed only twice over a period of three months. Considering this short time frame, those participants who linked framed their narratives more positively than those who did not.

Overall, the findings from this qualitative study indicate that linkers and nonlinkers represent transitory stages in the relapse-treatment-recovery cycle. There have been numerous quantitative studies that have examined barriers to substance abuse treatment entry (Redko, Rapp, & Carlson, 2006; Copeland, 1997). This qualitative study complements such studies by focusing on barriers to treatment linkage as well as facilitators to treatment linkage. Although treatment linkers and nonlinkers discussed many of the same themes when talking about why they did or did not link with treatment, the themes took on different meanings for linkers and nonlinkers.

Although the treatment career perspective may help to contextualize our findings, understanding why the factors associated with linkage and nonlinkage were experienced differently is an important research question. Longitudinal, qualitative studies are relatively rare in the field of substance abuse treatment (Carlson, 2006), but such perspective can help to add important insight into one of the nation's most important public health problems.