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. Author manuscript; available in PMC: 2015 Aug 1.
Published in final edited form as: Drug Alcohol Depend. 2014 Apr 5;139:152–158. doi: 10.1016/j.drugalcdep.2014.03.026

Preliminary Findings on the Association Between Clients’ Perceived Helpfulness of Substance Abuse Treatment and Outcomes: Does Race Matter?

LaTrice Montgomery 1,*, Blair Sanning 1, Nicole Litvak 1, Erica N Peters 2
PMCID: PMC4522021  NIHMSID: NIHMS708953  PMID: 24767892

Abstract

BACKGROUND

Few studies examine the helpfulness and effectiveness of substance abuse treatment from the clients’ perspective.

METHODS

The current secondary analysis examined the perceived helpfulness of substance abuse treatment components and its relationship to treatment outcomes among 387 Black and White adults participating in a multisite randomized clinical trial (RCT) of Motivational Enhancement Therapy. Throughout the 16-week RCT, participants self-reported substance use. Upon completion of treatment, participants completed a self-report measure assessing the perceived helpfulness of treatment components.

RESULTS

Black participants rated 9 out of 12 treatment components (e.g., “learning skills that will help me cope with my problems”) as being more helpful than their White counterparts, even after controlling for age, gender, employment status, primary drug type, and treatment assignment. However, perceived helpfulness ratings were not associated with substance use outcomes among Black or White participants.

CONCLUSIONS

Clients’ perceived helpfulness of treatment components is an important factor to consider in improving the delivery of substance abuse treatment, especially for Black adults.

Keywords: perceived helpfulness, substance abuse treatment, race

1. INTRODUCTION

Although several studies support the link between client attitudes and behavioral outcomes in non-substance-related domains, such as anxiety (Smith et al., 2012), depression (Gershefski et al., 1996) and personality disorders (Johansson et al., 2011), clients’ perceptions of substance abuse treatment and their relationships with treatment outcomes have received scant empirical attention. The dearth of literature in this area is striking given that an understanding of client perspectives on treatment has been widely recognized as a critical key to improving health care (Institute of Medicine, 2006; Urbanoski, 2010). In addition to gaining a more robust understanding of clients' attitudes regarding treatment and its relationship to treatment outcomes, there is a need for a better understanding of how the perceptions of substance abuse treatment experiences may differ for certain subgroups of clients, such as Black and White adults. This secondary analysis was designed to address these gaps by not only examining the relationship between the clients’ perceived helpfulness of substance abuse treatment components and treatment outcomes, but determining if the relationship varies by race in the United States (US).

1.1 Perceptions of Substance Abuse Treatment

Although research on the link between clients’ perception of treatment and treatment outcomes (e.g., substance use and retention) is scarce, some studies have focused on describing clients’ perceived helpfulness of substance abuse treatment (e.g., Deering et al., 2011; Gogel et al., 2011; Gordon et al., 2011; Joosten De-Weert, et al., 2011; Lovejoy et al., 1995; Merrick et al., 2012; Palmer et al., 2009; Reisinger et al., 2009; Tuchman and Sarasohn, 2011; Vederhus et al., 2011; Winstock et al., 2011). For example, among clients participating in either an inpatient substance abuse treatment facility or an outpatient opioid maintenance treatment clinic in a Western European country, Nordfjaern et al. (2010) found that patients rated therapeutic alliance and mutual influences among patients (i.e., positive and reinforcing interpersonal relationships with other patients in substance abuse treatment) as helpful components of treatment. The clients also reported that frequent staff turnover negatively influenced their perceptions of treatment. Other studies have also assessed the helpfulness of specific aspects of substance abuse treatment, such as physical activity (Abrantes et al., 2011), cultural responsiveness (Vandevelde et al., 2003) and medication components (Gryczynski et al., 2013; Kelly et al., 2012). However, these studies did not focus on the relationship between perceived helpfulness of substance abuse treatment and treatment outcomes.

1.2 Relationship between Perceptions of Substance Abuse Treatment and Treatment Outcomes

This relationship was first examined in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (NIDA CCTS; Siqueland et al., 2004). Findings from the NIDA CCTS revealed that treatment helpfulness ratings were positively associated with retention and therapeutic alliance, but were not associated with changes in drug use or psychiatric outcomes. Another study (Lee et al., 2007) also examined the relationship between perceived helpfulness of treatment components and outcomes among adults participating in a brief intervention for alcohol. The authors found that higher client ratings of “I have obtained some new understanding” was a significant predictor of reduced total number of alcohol consequences (e.g., hangovers, missed days from school or work) at a 12-month follow up among participants who received the brief alcohol intervention and a booster session. Similarly, Zhiwei et al. (2008) found that a favorable evaluation of treatment near the time of discharge from clients participating in a methadone, outpatient, short-term residential or long-termresidential program was positively related to drug use improvement outcomes during a 1 year follow-up. In another study of overall client satisfaction with treatment, Donovan et al. (2002) found that higher levels of client satisfaction with treatment were associated with higher levels of therapy attendance, greater reductions in drinking during therapy and better clinical status at the end of treatment in Project MATCH (i.e., a multisite clinical trial of alcohol treatment). These studies suggest a relationship between clients’ attitudes towards the treatment process and treatment outcomes.

Although these studies examined the relationship between clients’ perceived helpfulness of treatment and substance use outcomes, several gaps still exist in the literature. First, these studies are limited in number, thereby reducing the implications that can be drawn from this body of literature. Second, some studies do not support the relationship between client attitudes and treatment outcomes (e.g., Carlson and Gabriel, 2001; Gerstein and Harwood, 1990; McLellan and Hunkeler, 1998; Simpson, 2004). The inconsistent findings across existing studies highlight a need for more research to fully assess the aforementioned relationship. Third, to the authors’ knowledge, no studies have examined if the association between the clients’ perceived helpfulness of treatment and treatment outcomes varies by patient factors, such as race.

1.3 Racial Differences in Substance Abuse Treatment

Race may be one particular patient factor that may account for differences in the association between clients’ perceived helpfulness of treatment and treatment outcomes in the US. However, the lack of knowledge on racial differences in this area is alarming given the significant number of racial health disparities documented in the substance abuse treatment literature (e.g., Cooper et al., 2010; Cummings et al., 2011; Harris et al., 2012; Magruder et al., 2009; Montgomery et al., 2012; Shillington and Clapp, 2000). For example, Milligan et al. (2004) found that Black participants living in the United States completed significantly fewer days of treatment than their White counterparts. Further, Montgomery et al. (2011) found that Motivational Enhancement Therapy (MET) was not effective in reducing substance use in a predominately Black cocaine-using sample. However, in another study, substance use outcomes were favorable among a predominately White cocaine-using sample participating in MET (Stein et al., 2009). Different responses to treatment such as these suggest that clients’ perceptions of treatment might also vary by race.

1.4 Racial Differences in Perceptions of Treatment

Although no studies have directly examined racial variation in the relationship between perceived helpfulness of substance abuse treatment and treatment outcomes, a limited number of studies conducted on evidence-based substance abuse treatments, such as nicotine replacement therapy (NRT) for smoking cessation, have found racial differences in the perception of treatment. For example, Carpenter et al. (2011) found that Black smokers expressed concern about NRT safety and a strong suspicion of the pharmaceutical industry and government oversight, while White smokers expressed concerns about NRT safety only, and did so to a lesser degree than the Black and Hispanic smokers. The authors suggested that enduring misperceptions about NRT might partially contribute to the underutilization of NRT among racial minorities. Other studies have also noted varying perceptions of NRT among Black adults (Fu et al., 2007; Ryan et al., 2011; Yerger et al., 2008).

1.5 Current Study

The secondary analysis was designed to examine the relationship between perceived helpfulness of treatment components and substance use outcomes overall and specifically between Black and White adults in the US participating in MET and treatment as usual (TAU). This secondary analysis of a National Institute on Drug Abuse (NIDA) sponsored clinical trial was designed to answer two questions: First, do the perceived helpfulness ratings of substance abuse treatment components vary between Black and White adults? Based on existing literature with Black smokers (e.g., Fu et al., 2007; Ryan et al., 2011; Yerger et al., 2008), it was hypothesized that ratings of perceived helpfulness of substance abuse treatment components would vary between Black and White adults. Second, does the relationship between perceived helpfulness of treatment components and treatment outcomes vary between Black and White adults? Although there is no empirical evidence upon which to hypothesize the nature of the relationship between perceived helpfulness of treatment components and treatment outcomes, existing findings on racial differences in perceptions of substance abuse treatment, plus existing findings on racial differences in treatment outcomes, point to the logical next step of examining whether the relationship between perceived helpfulness of treatment and treatment outcomes also varies by race. Such an examination would address a critical need for a stronger understanding of client perceptions of substance abuse treatment and factors that contribute to positive substance abuse treatment outcomes. Moreover, results from such an examination may at least partially explain racial health disparities observed in substance abuse treatment.

2. METHOD

2.1 Participants

Participants included in these analyses were from the National Drug Abuse Treatment Clinical Trials Network (CTN) 0004 trial (N = 461) examining the effectiveness of MET in reducing substance use. Participants who self-identified as being only “Black, African American or Negro” (n = 194) or “White” (n = 193) on the demographic form were included in the present study. Individuals who self-identified as Hispanic American (10.6%) or other race (5.4%) were excluded from the analyses due to the small number of participants. The demographic information and the CONSORT diagram outlining eligibility, enrollment, randomization, treatment and follow-up rates for the entire CTN 0004 sample (Ball et al., 2007) and for Black participants (Montgomery et al., 2011) are available elsewhere. The demographic information for Black and White participants in the current study is shown in Table 1. Individuals who: (1) were seeking outpatient treatment for any substance use disorder, (2) had used substances within 28 days prior to the study, (3) were 18 years of age or older, (4) were willing to participate in the protocol, and (5) were able to understand and provide written informed consent were eligible to participate in the trial. Individuals too medically or psychiatrically unstable to participate in outpatient treatment and/or individuals only seeking detoxification, methadone maintenance treatment or residential treatment were excluded.

Table 1.

Demographic Characteristics of Black and White Participants in Clinical Trials Network 0004 Study

Characteristics (%) Black (N = 194) White (N = 193) Total (N = 387)
Men 75.3 66.3 70.8
Women 24.7 33.7 29.2
Marital Status (married) 16.0 13.5 14.7
Employed 41.2 48.7 45.0
Mandated to Treatment (yes) 27.3 26.4 26.9
Treatment Assignment
    MET 43.8 50.8 47.3
    TAU 56.2 49.2 52.7
Primary Drug
    Cocaine 25.8 17.1 21.4
    Alcohol 26.3 33.7 30.0
    Marijuana 18.0 11.4 14.7
    2 or More 24.2 24.2 13.2
    Other 5.6 13.6 20.7
Age (years, M[SD]) 37.52 (9.93) 33.41 (10.08) 35.47 (10.20)
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*Please note that there no significant differences between Black and White individuals on any of the demographic variables displayed in the table above.

2.1.1 Participating CTPs

The five participating community treatment programs (CTPs) provided outpatient treatment in a non-methadone maintenance setting. CTPs that (1) enrolled adequate numbers of new patients to meet the recruitment targets for the parent study (i.e., 100 participants per CTP, with approximately 50 participants per treatment group) and (2) had at least six clinicians willing to participate in the protocol were eligible to participate. CTPs from Connecticut, Pennsylvania, and California participated in this trial. Further details are provided elsewhere (Ball et al., 2007).

2.1.2 Participating clinicians

Clinicians who were (1) currently employed at the participating CTPs, (2) willing to utilize a manualized version of MET, (3) willing to accept an assignment to either MET or standard treatment, and (4) approved by the CTPs’ administrative/supervisory staff as appropriate for the study were eligible to participate in CTN 0004. Clinicians with prior MI/MET training were ineligible. Further information on clinician eligibility criteria and training plans can be found in the CTN 0004 protocol (Carroll et al., 2001).

2.2 Measures

2.2.1 Substance Use Calendar (SUC)

The two outcome measures (i.e., total number of days of primary substance use during the 16 study weeks and total number of days of other substance use during the 16 study weeks) were assessed using the SUC. The SUC is a self-report substance use (marijuana, cocaine, alcohol, methamphetamine, benzodiazepines, opioids and other illicit substances) measure that asks participants to retrospectively report use on each day of the assessment period. Participants reported their primary and other substance use on a weekly basis during the 16 study weeks. The SUC is adapted from the Form-90 and Timeline Followback (TLFB), two widely used measures of substance use in calendar form (i.e., day to day). The Form-90 (Miller and DelBoca, 1994) and TLFB (Ehrman and Robbins, 1994; Fals-Stewart et al., 2000; Sobell and Sobell, 1992) have both demonstrated good reliability and validity in assessing substance use.

2.2.2. Posttreatment Attitudes and Expectation Questionnaires

The Posttreatment Attitudes and Expectations Questionnaire is a 36-item self-report questionnaire administered at the final treatment session of the 16-week treatment period to assess participant satisfaction with treatment. Participants were asked to rate their satisfaction with the treatment they received, their degree of change during treatment and their perception of helpful or harmful aspects of the treatment they received. This form has been used successfully in Project MATCH and the Center for Substance Abuse Treatment multisite marijuana treatment trial (Donovan et al., 2002). The 12 items assessing perceived helpfulness of treatment components were: (1) “talking about things that happened to me when I was growing up”, (2) “learning skills that will help me cope with my problems”, (3) “learning how to deal with my family conflicts”, (4) “learning about the effects of drugs/alcohol on my body and mind”, (5) “teaching my family about how to help me stop using”, (6) “going to Alcoholics Anonymous [AA], Cocaine Anonymous [CA], and/or Narcotics Anonymous [NA]”, (7) “monitoring of my drug use through urine testing”, (8) “learning skills on how to deal with situations that tempt me to use drugs/alcohol”, (9) “being able to call sober friends when I need help”, (10) “treatment for emotional problems like depression or anxiety”, (11) “just being in treatment”, and (12) “helping me get along better with the people who are important to me and improving my social life.” The lead-in statement for each of the 12 items was: “Now we would like to know what things you feel were most helpful to you in your treatment. Please indicate how helpful you believe each of the following was for you.” Each item was measured on a 7-point Likert-scale ranging from 0-6 (0 = did not happen in my treatment, 1 = slightly helpful, 2 = somewhat helpful, 3 = moderately helpful, 4 = helpful, 5= very helpful, 6 = extremely helpful). Between 2 -21% of responses were coded as 0 on each of the 12 items.

2.2.3 Demographic and Substance Use Characteristics

At baseline, participants self- reported gender, marital status, age, employment status, race/ethnicity, treatment assignment, primary drug type, and whether or not they were mandated to treatment.

2.3 Procedures

The research team identified and referred potentially eligible individuals seeking outpatient substance abuse treatment at each of the participating five CTPs to a research assistant. Research assistants obtained written consent and collected baseline information from eligible and interested participants. Participants were then randomly assigned via urn randomization to receive TAU or MET. The variables used in the original study for urn randomization included gender, race, primary substance, referral type (mandated or voluntary) and employment status (Stout et al., 1994). After randomization, participants began either three MET sessions in the active phase and TAU in the follow up phase (i.e., 12 weeks following the active phase) or three TAU sessions in the active phase and additional TAU sessions in the follow up phase. Research assistants met weekly with participants during the four week active phase and 12 week follow up phase to collect information on substance use and treatment utilization.

2.3.1 Treatment as Usual (TAU)

Participants attended three sessions (45-55 minutes each) during the four week active phase as an adjunct to TAU. Clinicians “collected information on substance use and psychosocial functioning, explained treatment program requirements, discussed the participant's treatment goals, provided early case management and substance abuse counseling, encouraged attendance at 12-step meetings, promoted abstinence, and emphasized follow through with treatment at the clinic” (Ball et al., 2007, p. 559). All clinicians met monthly with a supervisor to review individual patient treatment progress. Clinicians also submitted audiotaped sessions that were later rated by their supervisor and an independent tape rater for adherence and competence. Further details are available in Ball et al. (2007) and the CTN 0004 protocol (Carroll et al., 2001).

2.3.2 Motivational Enhancement Therapy (MET)

Participants in the MET condition attended three sessions (45-55 minutes each) during the four week active phase as an adjunct to TAU. Clinicians used a MET manual (Farentinos et al., 2000) developed for the CTN 0004 study. The manual describes “three carefully planned sessions, with the first session focused on reviewing an individualized Personal Feedback Report (i.e., summarizes objective and personal information on participant's substance use), and the other two focused on discussing plans for changing substance use” (Carroll et al., 2001, p. 12). The clinician's goal was to enhance the client's own motivation and commitment to change.

Further details on the demographics, training, supervision and certification of therapists in MET and TAU are provided elsewhere (Ball et al., 2007; Carroll et al., 2001). Independent ratings on adherence and competence rating scales indicated discriminability between MET and TAU in the expected directions, as described in the parent study (Ball et al., 2007).

2.4 Data Analysis Methods

Preliminary analyses included chi-square tests and t-tests to determine if baseline characteristics of Black and White adults in the study varied across racial groups. Cronbach alpha reliability coefficients were calculated on the 12 perceived helpfulness items for both Black and White participants, and a Feldt test was conducted to compare the two alpha reliabilities between Black and White individuals. Variables’ skewness and kurtosis were examined. Two variables on the Posttreatment Attitudes and Expectations Questionnaire, “learning skills on how to deal with situations that tempt me to use drugs/alcohol” and “just being in treatment”, were positively skewed; thus, logarithmic transformations were performed on the two variables and used in subsequent statistical analyses.

To evaluate whether the perceived helpfulness ratings of substance abuse treatment components varies between Black and White adults, a multivariate analysis of variance (MANOVA) was first conducted, with race entered as a factor and the 12 posttreatment perceived helpfulness items entered simultaneously as dependent variables. To further understand the effect of race, over and above potentially confounding influences, on perceived helpfulness ratings of substance abuse treatment components, a multivariate analysis of covariance (MANCOVA) was then conducted, with race entered as a factor, the 12 posttreatment perceived helpfulness items entered simultaneously as dependent variables, and covariates of age, gender, employment status, primary drug and treatment group. Partial eta squared (ηp2) was calculated to determine the proportion of the variance in the posttreatment items that is accounted for by race in the MANOVA and MANCOVA analyses.

To investigate whether the relationship between perceived helpfulness of treatment components and treatment outcomes varies by race, three steps were taken. First, partial correlation coefficients (controlling for age and employment status) assessed the relationship between the 12 post-treatment perceived helpfulness items and the substance use (i.e., number of days of primary substance use during the 16 study weeks) outcomes among all (i.e., both Black and White) participants. Second, separate partial correlation coefficients were conducted separately for Black and White adults. Third, Fisher's r-to-z transformations were performed to test for potential differences between correlations among Black and White adults.

To control for multiple comparisons, but allow for meaningful patterns to emerge from the data, significance level was set at .01 in each of the analyses. All analyses were performed via the Statistical Package for the Social Sciences (SPSS) Version 20.

3. RESULTS

3.1 Sample Characteristics

Demographic and substance use characteristics are shown in Table 1. No significant differences in demographic or substance use characteristics emerged between Black and White adults. Participants remained in treatment for an average of 78.53 (SD = 37.11) days out of 112 total days. The coefficient alpha for the Posttreatment Attitudes and Expectations Questionnaire was .891 for White participants and .890 for Black participants; a Feldt test did not reveal a significant difference between the two groups on these values (Wald = 0.99, p = 0.48).

3.2 Racial Variation in Perceived Helpfulness of Treatment Components

Results from the MANOVA and MANCOVA are shown in Table 2. MANOVA analyses revealed a significant main effect for race (Wilks’ λ = .862, F (12, 270) = 3.59, p < .01, ηp2 = 0.14) in the model. As shown in Table 2, race accounted for 3-10% of the variance in each of the items. Black participants reported significantly higher helpfulness ratings than their White counterparts on 9 of the 12 posttreatment items (i.e., “talking about things that happened to me when I was growing up”, “learning skills that will help me cope with my problems”, “learning how to deal with family conflicts”, “learning more about the effects of drug/alcohol on my body/,mind”, “teaching my family about how to help me stop using”, monitoring of my drug use through urine testing”, “learning skills on how to deal with situations that tempt me to use drugs/alcohol”, “just being in treatment” and “helping me get along better with the people who are important to me and improving my social life”).

Table 2.

Posttreatment Ratings of Perceived Helpfulness of Substance Abuse Treatment Components for Black and White Adults

Item African American (N = 142)
 Whites (N =141)
 Total (N = 283)
 MANOVA Results
 MANCOVA Results
M SD M SD M SD F df p η p2 F df p η p2
1 3.16 2.14 2.39 2.02 2.79 2.11 9.78 1 <.01 0.03 7.81 1 <.01 0.03
2 4.38 1.48 3.60 1.89 4.00 1.73 15.86 1 <.01 0.05 14.39 1 <.01 0.05
3 3.06 2.11 2.20 2.13 2.64 2.16 12.56 1 <.01 0.04 10.99 1 <.01 0.04
4 4.25 1.78 3.23 2.01 3.75 1.96 20.38 1 <.01 0.07 15.11 1 <.01 0.05
5 2.38 2.25 1.59 2.00 1.99 2.17 10.35 1 <.01 0.04 10.95 1 <.01 0.04
6 3.72 2.45 3.12 2.42 3.42 2.45 5.50 1 0.02 0.02 1.43 1 0.23 0.00
7 4.41 1.50 3.38 1.69 3.91 1.67 30.01 1 <.01 0.10 25.97 1 <.01 0.09
8 4.61 1.51 3.83 1.78 4.23 1.69 16.33 1 <.01 0.06 15.41 1 <.01 0.05
9 3.48 2.44 2.85 2.32 3.17 2.40 5.49 1 0.02 0.02 2.68 1 0.10 0.01
10 2.09 2.32 1.88 2.19 1.99 2.26 1.01 1 0.32 0.00 0.18 1 0.67 0.00
11 4.88 1.31 4.31 1.58 4.60 1.47 12.01 1 <.01 0.04 8.15 1 <.01 0.03
12 3.93 1.94 3.20 2.05 3.58 2.03 9.56 1 <.01 0.03 5.40 1 <.01 0.02
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Note. 1. Item Descriptions: 1 = “talking about things that happened to me when I was growing up”; 2 = “learning skills that will help me cope with my problems”; 3 = “learning how to deal with my family conflicts”; 4 = “learning about the effects of drugs/alcohol on my body and mind”; 5 = “teaching my family about how to help me stop using”; 6 = “going to Alcoholics Anonymous [AA], Cocaine Anonymous [CA], and/or Narcotics Anonymous [NA]”; 7 = “monitoring of my drug use through urine testing”; 8 = “learning skills on how to deal with situations that tempt me to use drugs/alcohol”; 9 = “being able to call sober friends when I need help”; 10 = “treatment for emotional problems like depression or anxiety”; 11= “just being in treatment”; 12 = “helping me get along better with the people who are important to me and improving my social life.”

2.Likert scale for items: 0 =did not happen in my treatment, 1 = slightly helpful, 2 = somewhat helpful, 3 = moderately helpful, 4 = helpful, 5 = very helpful, 6 = extremely helpful.

3.MANCOVA results reported in this table control for age, gender, employment status, primary drug type and treatment assignment.

After controlling for age, gender, employment status, primary drug type and treatment group in MANCOVA analyses, analyses revealed a significant main effect for race (Wilks’ λ = .866, F (12, 265) = 3.43, p < .01, ηp2 = 0.13) in the model. As shown in Table 2, race accounted for 3-9% of the variance in each of the items. Black individuals reported significantly higher helpfulness ratings than White participants on the same 9 treatment components listed in the MANOVA results above. MANCOVA analyses also revealed a significant main effect for age (Wilks’ λ = .814, F (12, 261) = 4.97, p < .01, ηp2 = 0.19) and employment status (Wilks’ λ = .902, F (12, 261) = 2.36, p < .01, ηp2 = 0.10), but no significant main effects for gender, primary drug, or treatment group. Age and employment status were controlled for in subsequent analyses.

3.3 Racial Variation in the Relationship of Perceived Helpfulness of Treatment Components and Treatment Outcomes

Partial correlation coefficients (controlling for age and employment status) did not reveal any significant relationships between perceived helpfulness items and substance use outcomes for the overall sample. Therefore, no significant associations were found in the partial correlation coefficient analyses conducted separately for Black and White participants, as shown in Table 3. The Fisher's r-to-z transformations were also non-significant.

Table 3.

Partial Correlations Between Perceived Helpfulness of Treatment and Substance Use and Retention Outcomes by Race

Item Days of Primary Drug Use Days of Other Drug Use
African American White z African American White z
1 −0.14 0.02 −1.34 −0.04 −0.08 0.33
2 0.07 −0.09 1.33 0.06 −0.08 1.17
3 −0.02 −0.04 0.17 −0.04 −0.06 0.17
4 −0.06 0.04 −0.83 0.05 −0.05 0.83
5 0.04 −0.01 0.42 0.08 −0.01 0.75
6 −0.10 −0.09 0.67 −0.01 0.02 −0.25
7 −0.04 0.01 −0.42 0.01 0.02 −0.08
8 −0.06 −0.05 −0.08 −0.03 −0.09 0.50
9 −0.01 −0.14 1.09 0.09 −0.15 2.01
10 0.03 −0.03 0.50 0.02 0.01 0.08
11 −0.01 −0.10 0.75 −0.02 0.06 −0.67
12 −0.01 −0.05 0.33 0.06 −0.13 1.59
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Note. 1. p < .01

2.Item Descriptions: 1 = “talking about things that happened to me when I was growing up”; 2 = “learning skills that will help me cope with my problems”; 3 = “learning how to deal with my family conflicts”; 4 = “learning about the effects of drugs/alcohol on my body and mind”; 5 = “teaching my family about how to help me stop using”; 6 = “going to Alcoholics Anonymous [AA], Cocaine Anonymous [CA], and/or Narcotics Anonymous [NA]”; 7 = “monitoring of my drug use through urine testing”; 8 = “learning skills on how to deal with situations that tempt me to use drugs/alcohol”; 9 = “being able to call sober friends when I need help”; 10 = “treatment for emotional problems like depression or anxiety”; 11= “just being in treatment”; 12 = “helping me get along better with the people who are important to me and improving my social life.”

3.Partial correlation coefficient analyses controlled for age and employment status.

4. DISCUSSION

Client perspectives on the effectiveness of substance abuse treatment and its relationship to treatment outcomes are often overlooked in the literature. This secondary analysis was designed to address this gap by examining, first, the relationship between clients' perceived helpfulness of treatment components and treatment outcomes and, second, racial variation in this relationship among individuals living in the United States. Findings revealed racial variation in the perceived helpfulness of most treatment components, even after controlling for other demographic factors (e.g., age). However, perceived helpfulness ratings were not associated with substance use outcomes among Black or White participants.

Black adults endorsed higher perceived helpfulness ratings than their White counterparts on all treatment components, with the exception of equally helpful ratings among both racial groups on “treatment for emotional problems like depression or anxiety”, “going to AA, NA and/or CA” and “being able to call sober friends when I need help.” Overall, findings suggest that Black adults perceive treatments that focus on teaching new coping skills and information about the intersection between drug use and interpersonal relationships as more helpful than their White counterparts. The findings corroborate previous findings, which suggest that racial/ethnic minorities tend to find services from any mental health service providers and generalist providers as more helpful than non-racial/ethnic minorities (Jackson et al., 2007; Redmond et al., 2009). Further, many of the components (e.g., learning new information and skills) that Black adults rated as most helpful in this study have been found to be effective among other samples of Black adults in substance abuse treatment. For example, Ahluwalia et al. (2006) found that Black light smokers receiving 2 mg nicotine gum plus health education (i.e., directive information and advice-oriented counseling on smoking cessation) reported higher seven-day quit rates than those receiving 2 mg nicotine gum plus motivational interviewing.

Even after controlling for age, gender, primary drug type, employment status and treatment group, race still explained 13% of the overall variance in the posttreatment item ratings as compared to 14% in the model that did not control for other baseline characteristics. This finding suggests that race is an important demographic characteristic to consider in substance abuse treatment preferences. Several studies have demonstrated the importance of considering racial differences in mental health treatment preferences (Cooper et al., 2003; Mulaney et al., 2011). For example, Jimenez et al., 2012 found that Black adults were more likely than their non-Latino White counterparts to report that they would seek spiritual advice to help them with a mental health problem. Although several studies support the relationship between race/ethnicity and attitudes towards mental health treatment, a smaller number of studies examine the link between race/ethnicity and attitudes towards substance abuse treatment. Findings from the current study highlight the need for future research that examines substance abuse treatment experiences, especially among Black participants, to perhaps explain racial/ethnic health disparities observed in treatment outcomes (Cook and Alegria, 2011; Guerrero et al., 2013).

Although Black participants rated most of the treatment components as more helpful than their White counterparts, the ratings were not associated with decreased primary or other drug use during treatment among Black or White participants. This finding was unexpected given extant literature demonstrating a relationship between high perceived helpfulness ratings and positive substance abuse treatment outcomes (Lee et al., 2007; Zhiwei et al., 2008). There are some plausible explanations for this unexpected finding. First, it is possible that participants did not receive a high frequency of the component that was rated as helpful. Second, even if participants did receive a particular treatment component, participants may not have learned how to effectively implement the treatment component in their lives. The lack of sufficient exposure to helpful treatment components and/or the lack of understanding about how to enact treatment components outside of treatment might partially explain why the perceived helpfulness of the component did not translate into decreased substance use. Future studies should examine both the frequency and skill in which the treatment components are delivered, as these factors might contribute to changes in outcome (Miller et al., 2006; Waltz et al., 1993).

Third, patient factors besides race might also influence, or might interact with race to influence, the relationship between perceived helpfulness of treatment and outcomes. Age and employment status may be two such examples of patient factors, as they accounted for 19% and 10% of the variance in posttreatment item ratings, respectively, in the current study and have been found to influence treatment attitudes in the mental health treatment literature (Gonzalez et al., 2011). Other factors, such as therapeutic alliance (Bachelor, 2013), should also be examined when assessing the relationship between perceived helpfulness of treatment and substance use outcomes. Fourth, the authors of the parent study (Ball et al., 2007) found site differences in substance use outcomes. For example, four sites showed decreased substance use during the first four weeks of the study, while one site showed less change. It is plausible that perceived helpfulness ratings may have varied across the five treatment sites in this study and may have influenced substance use outcomes differently.

This study has several strengths. First, this is among one of the few studies to examine clients’ perceived helpfulness of substance abuse treatment and its relationship to treatment outcomes. Second, this is the first study to examine racial variation in the aforementioned relationship. Third, this study used data from a high-quality multi-site RCT of diverse substance users. Fourth, this study aligns with two National Institutes of Health (NIH) initiatives, including the NIH Guidelines on the Inclusion of Women and Minorities (NIH, 2001) and the Strategic Plan on Health Disparities Research of the National Institute on Drug Abuse (NIDA; NIDA, 2004), which require both the inclusion of racial/ethnic minorities in clinical trials and valid analyses to detect intervention effects among racial/ethnic minorities.

Although this study has several strengths, a few limitations are noteworthy. First, the effect sizes for the statistically significant differences between Blacks and Whites on the perceived helpfulness items were small to medium, which may have been partly due to the small sample size. In addition, the current study was a secondary analysis of existing data that was not specifically designed to answer the research questions raised in this study. Future research should include studies that are sufficiently powered to examine racial differences in the relationship between perceived helpfulness of treatment and treatment outcomes.

Second, the single-item measure of perceived treatment helpfulness might not have captured the multi- dimensional nature of attitudes towards treatment. For example, an individual might have identified self-help groups as being extremely helpful, but may have attended few groups due to transportation issues. A potential consequence is that he/she may have displayed poor treatment outcomes because he/she did not attend groups often enough to receive substantial benefit. In this case, the single Likert-scale item does not assess how often the individual was able to engage in or benefit from the treatment components. Future studies should use a multidimensional measure of attitudes rather than a single-item measure of treatment attitudes to capture the complexity of this construct. Other limitations of the parent study design are noted elsewhere (Ball et al., 2007). Despite these limitations, the current findings have valuable clinical and research implications for Black and White adults in substance abuse treatment.

Implications/Future Research

First, findings from this study suggest that the perceived helpfulness of substance abuse treatment components varies by race. Blacks adults rated most of the treatment components as more helpful than their White counterparts. This finding corroborates existing research (e.g., Alegria et al., 2007) and suggests that clinicians and researchers should consider the influence of race when discussing or analyzing clients’ perceived helpfulness of treatment. The higher perceived helpfulness ratings among Black adults reported here counters existing research highlighting Blacks’ negative perception of behavioral treatments (e.g., Thompson et al., 2004, 2009). As shown in this study, other variables (e.g., age and employment status) might influence how Black individuals perceive treatment. Future research should continue to examine the influence of demographic or other patient factors on perceived helpfulness treatment ratings among Black adults to elucidate the factors that are related to favorable treatment components among this population. Further, future studies should assess if perceived helpfulness impacts more proximal outcomes, such as enhanced motivation to change (DiClemente et al., 2004) or increased self-efficacy (Kadden and Litt, 2011), which have been shown to influence substance use outcomes.

Second, although treatment outcomes were not related to perceived helpfulness among Black or White adults in this study, findings still revealed higher ratings of specific treatment components among Black adults. Future studies should focus on the important components endorsed by Black adults (e.g., learning how to deal with family conflicts) and determine if they translate into decreased substance use in other subgroups of the Black population. Future research should also examine how baseline characteristics, such as severity of drug use (Montgomery et al., under review; Petry et al., 2012) and prior engagement in treatment (Cacciola et al., 2009), might influence the potential benefits that Black adults report receiving from treatment. This type of research might help to at least partially explain and address racial health disparities observed in substance abuse treatment.

Acknowledgements

The authors would like to thank Dr. Kathleen Carroll and the National Drug Abuse Treatment Clinical Trials Network for sharing data for this project. The authors would also like to thank Kevin O'Grady, Ph.D. at the Friends Research Institute for his statistical consultation during the preparation of this manuscript.

Role of funding source

None declared.

Footnotes

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Contributors

Dr. Montgomery undertook the statistical analysis and wrote the first draft of the manuscript. Blair Sanning made a substantial contribution to the writing of the manuscript. Nicole Litvak made a substantial contribution to the writing of the manuscript. Dr. Peters edited drafts of the manuscript and provided comments on the statistical analysis. All authors have contributed to and have approved the final manuscript.

Conflict of Interest

All authors declare that they have no conflicts of interest.

REFERENCES

  1. Abrantes AM, Battle CL, Strong DR, Ing E, Dubreuil ME, Gordon A, Brown RA. Exercise preferences of patients in substance abuse treatment. Ment. Health Phys. Act. 2011;4:79–87. doi: 10.1016/j.mhpa.2011.08.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Ahluwalia JS, Okuyemi K, Nollen N, Choi WS, Kaur H, Pulvers K, Mayo MS. The effects of nicotine gum and counseling among African American light smokers: A 2 × 2 factorial design. Addiction. 2006;101:883–891. doi: 10.1111/j.1360-0443.2006.01461.x. [DOI] [PubMed] [Google Scholar]
  3. Alcoholics Anonymous (AA) Alcoholics Anonymous. 4th ed. Alcoholics Anonymous World Services; New York: 2001. Chapter 5: How it Works. [Google Scholar]
  4. Assari S. Race and ethnicity, religion involvement, church-based social support and subjective health in United States: acase of moderated mediation. Int. J. Prev. Med. 2013;4:208–217. [PMC free article] [PubMed] [Google Scholar]
  5. Bachelor A. Clients’ and therapists’ views of the therapeutic alliance: similarities, differences and relationship to therapy outcome. Clin. Psychol. Psychother. 2013;20:118–135. doi: 10.1002/cpp.792. [DOI] [PubMed] [Google Scholar]
  6. Ball SA, Martino S, Nich C, Frankforter TL, Van Horn D, Crits-Christoph P, Woody GE, Obert JL, Farentinos C, Carroll KM. Site matters: multisided randomized trial of motivational enhancement therapy in community drug abuse clinics. J. Consul.t Clin. Psychol. 2007;75:556–567. doi: 10.1037/0022-006X.75.4.556. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Burlew K, Weekes JC, Montgomery L, Feaster DJ, Robbins MS, Rosa CL, Ruglass LM, Venner KL, Wu L. Conducting research with racial/ethnic minorities: Methodological lessons from the NIDA Clinical Trials Network. Am J Drug Alcohol Abuse. 2011;37:324–332. doi: 10.3109/00952990.2011.596973. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cacciola JS, Dugosh KL, Camilleri AC. Treatment history: relationship to treatment outcomes. Subst. Use Misuse. 2009;44:305–321. doi: 10.1080/10826080802344732. [DOI] [PubMed] [Google Scholar]
  9. Carlson MJ, Gabriel RM. Patient satisfactions, use of services, and one-year outcomes in publicly funded substance abuse treatment. Psychiatr. Serv. 2001;52:1230–1236. doi: 10.1176/appi.ps.52.9.1230. [DOI] [PubMed] [Google Scholar]
  10. Carroll K, Ball S, Crits-Cristoph P, Farentinos C, McLellan T, Morgenstern J, Woody G, Clinical Trial Network (CTN) 0004 . Protocol: motivational enhancement treatment to improve treatment engagement and outcome in individuals seeking treatment for substance abuse. National Institute of Drug Abuse; Bethesda, MD: 2001. [Google Scholar]
  11. Carpenter MJ, Ford ME, Cartmell K, Alberg AJ. Misperceptions of nicotine replacement therapy within racially and ethnically diverse smokers. J. Nat. Med. Assoc. 2011;103:885–894. doi: 10.1016/s0027-9684(15)30444-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Chatters LM, Taylor RJ, Bullard KM, Jackson JS. Race and ethnic differences in religious involvement: African Americans, Caribbean Blacks and Non-Hispanic Whites. Ethn. Racial Stud. 2009;32:1143–1163. doi: 10.1080/01419870802334531. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Cook BL, Alegria M. Racial-ethnic disparities in substance abuse treatment: the role of criminal history and socioeconomic status. Psychiatr. Serv. 2011;62:1273–1281. doi: 10.1176/appi.ps.62.11.1273. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Cooper LA, Gonzales JJ, Gallo JJ, Rost KM, Meredith LS, Rubenstein LV, Wang NY, Ford DE. The acceptability of treatment for depression among African-American, Hispanic and White primary care patients. Med. Care. 2003;41:479–489. doi: 10.1097/01.MLR.0000053228.58042.E4. [DOI] [PubMed] [Google Scholar]
  15. Cooper RL, MacMaster S, Rasch R. Racial differences in retention in residential substance abuse treatment: the impact on African American men. Res. Soc. Work Pract. 2010;20:183–190. [Google Scholar]
  16. Cummings JR, Wen H, Druss BG. Racial/ethnic differences in treatment for substance use disorders among U.S. adolescents. J. Am. Acad. Child Adolesc. Psychiatry. 2011;50:1265–1274. doi: 10.1016/j.jaac.2011.09.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Debnam K, Holt CL, Clark EM, Roth DL, Southward P. Relationships between religious social support and general social support with health behaviors in a national sample of African Americans. J. Behav. Med. 2012;35:179–189. doi: 10.1007/s10865-011-9338-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Deering DE, Sheridan J, Sellman JD, Adamson SJ, Pooley S, Robertson R, Henderson C. Consumer and treatment provider perspectives on reducing barriers to opioid substitution treatment and improving treatment attractiveness. Addict. Behav. 2011;36:636–642. doi: 10.1016/j.addbeh.2011.01.004. [DOI] [PubMed] [Google Scholar]
  19. Delucchi KL, Kaskutas LA. Following problem drinkers over eleven years: understanding changes in alcohol consumption. J. Stud. Alcohol Drugs. 2010;71:831–836. doi: 10.15288/jsad.2010.71.831. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Diclemente CC, Schlundt D, Gemmell L. Readiness and stages of change in addiction treatment. Am. J. Addict. 2004;13:103–119. doi: 10.1080/10550490490435777. [DOI] [PubMed] [Google Scholar]
  21. Donovan DM, Kadden RM, DiClemente CC, Carroll KM. Client's satisfactions with three therapies in treatment of alcohol dependence: results from project MATCH. Am. J. Addict. 2002;11:231–307. doi: 10.1080/10550490290088090. [DOI] [PubMed] [Google Scholar]
  22. Ehrman RN, Robbins SJ. Reliability and validity of 6-month timeline reports of cocaine and heroin use in a methadone population. J. Consult. Clin. Psychol. 1994;62:843–850. doi: 10.1037//0022-006x.62.4.843. [DOI] [PubMed] [Google Scholar]
  23. Fals-Stewart W, O'Farrell TJ, Freitas TT, McFarlin SK, Rutigliano P. The timeline followback reports of psychoactive substance use by drug-abusing patients: psychometric properties. J. Consult. Clin. Psychol. 2000;68:134–144. doi: 10.1037//0022-006x.68.1.134. [DOI] [PubMed] [Google Scholar]
  24. Ferrari JR, Groh DR, Rulka G, Jason LA, Davis MI. Coming to terms with reality: predictors of self-deception within substance abuse recovery. Addict. Disord. Their Treat. 2008;7:210–218. doi: 10.1097/ADT.0b013e31815c2ded. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Fiorentine R, Nakashima J, Anglin D. Client engagement in drug treatment. J. Subst. Abuse Treat. 1999;17:199–206. doi: 10.1016/s0740-5472(98)00076-2. [DOI] [PubMed] [Google Scholar]
  26. Frank A, Thase M, Luborsky L, Liese B. What aspects of treatment matter to the patient in the treatment of cocaine dependence? J. Subst. Abuse Treat. 2004;27:169–178. doi: 10.1016/j.jsat.2004.06.007. [DOI] [PubMed] [Google Scholar]
  27. Fu SS, Burgess D, van Ryn M, Hatsukami DK, Solomon J, Joseph AM. Views on smoking cessation methods in ethnic minority communities: a qualitative investigation. Prev. Med. 2007;44:235–240. doi: 10.1016/j.ypmed.2006.11.002. [DOI] [PubMed] [Google Scholar]
  28. Gershefski JJ, Arnkoff DB, Glass CR, Elkin I. Client's perceptions of treatment for depression: I. helpful aspects. Psychother. Res. 1996;6:233–247. [Google Scholar]
  29. Gerstein DR, Harwood HJ, editors. Treating Drug Problems: A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment Systems. Vol. 1. Institute of Medicine; Washington, D.C.: 1990. [PubMed] [Google Scholar]
  30. Gogel LP, Cavaleri MA, Gardin JD, 2nd, Wisdom JP. Retention and ongoing participation in residential substance abuse treatment: perspectives from adolescent, parents and staff on treatment process. J. Behav. Health Serv. Res. 2011;38:488–496. doi: 10.1007/s11414-010-9226-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Gonzalez JM, Alegria M, Prihoda TJ, Copeland LA, Zeber JE. How the relationship of attitudes toward mental health treatment and service use by age, gender, ethnicity/race and education. Soc. Psychiatry Psychiatr. Epidemiol. 2011;46:45–57. doi: 10.1007/s00127-009-0168-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Gordon AJ, Ettaro L, Rodriguez KL, Mocik J, Clark DB. Provider, patient, and family perspectives of adolescent alcohol use and treatment in rural settings. J. Rural Health. 2011;27:81–90. doi: 10.1111/j.1748-0361.2010.00321.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Gryczynski J, Jaffe JH, Schwartz RP, Dušek KA, Gugsa N, Monroe CL, O'Grady KE, Olsen YK, Mitchell SG. Patient perspectives on choosing buprenorphine over methadone in an urban, equal-access system. Am. J. Addict. 2013;22:285–291. doi: 10.1111/j.1521-0391.2012.12004.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Guerrero EG, Marsh JC, Duan L, Oh C, Perron B, Lee B. Disparities in completion of substance abuse treatment between and within racial and ethnic groups. Health Serv. Res. 2013;48:1450–1467. doi: 10.1111/1475-6773.12031. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Harris N, Brazeau JN, Clarkson A, Brownlee K, Rawana EP. Adolescents’ experiences of a strength-based treatment program for substance abuse. J. Psychoactive Drugs. 2012;44:390–397. doi: 10.1080/02791072.2012.736822. [DOI] [PubMed] [Google Scholar]
  36. Humphreys K. Circles of Recovery: Self-Help Organizations for Addictions. Cambridge University Press; Cambridge, UK: 2004. [Google Scholar]
  37. Humphreys K, Moos R. Can encouraging substance abuse patients to participate in self-help groups reduce demands for health care? A quasi-experimental study. Alcohol. Clin. Exp. Res. 2001;25:711–716. [PubMed] [Google Scholar]
  38. IBM Corp. IBM SPSS Statistics for Windows, Version 20.0. IBM Corp.; Armonk, NY: 2011. Released. [Google Scholar]
  39. Institute of Medicine . Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC: 2006. [Google Scholar]
  40. Jackson JS, Neighbors HW, Torres M, Baser R, Martin LA, Williams DR. Use of mental health services and subjective satisfaction with treatment among black caribbean immigrants: results from the national survey of american life. Am. J. Public Health. 2007;97:60–67. doi: 10.2105/AJPH.2006.088500. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Jimenez DE, Bartels SJ, Cardenas V, Daliwal SS, Alegria M. Cultural beliefs and mental health treatment preferences of ethnically diverse older adult consumers in primary case. Am. J. Geriatr. Psychiatry. 2012;20:533–542. doi: 10.1097/JGP.0b013e318227f876. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Joosten EAG, De Weert-Van Oene GH, Sensky T, Van Der Staak CPF, De Jong CAJ. Treatment goals in addiction healthcare: the perspectives of patients and clinicians. Int. J. Soc. Psychiatry. 2011;57:263–276. doi: 10.1177/0020764009354835. [DOI] [PubMed] [Google Scholar]
  43. Kaskutas LA. Alcoholism anonymous effectiveness: faith meets science. J. Addict. Dis. 2009;28:145–157. doi: 10.1080/10550880902772464. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Kaskutas LA, Weisner C, Lee M, Humphreys K. Alcoholics Anonymous affiliation at treatment intake among white and black Americans. J. Stud. Alcohol. 1999;60:810–816. doi: 10.15288/jsa.1999.60.810. [DOI] [PubMed] [Google Scholar]
  45. Kelly SM, Brown BS, Katz EC, O'Grady KE, Mitchell SG, King S, Schwartz RP. A comparison of attitudes toward opioid agonist treatment among short-term buprenorphine patients. Am. J. Drug Alcohol Abuse. 2012;38:233–238. doi: 10.3109/00952990.2011.643983. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Kelly JF, Stout RL, Magill M, Tonigan JS, Pagano ME. Spirituality in recovery: a lagged mediational analysis of alcoholics anonymous’ principal theoretical mechanism of behavior change. Alcohol. Clin. Exp. Res. 2011;35:454–463. doi: 10.1111/j.1530-0277.2010.01362.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Ferraro KF, Koch JR. Religion and health among black and white adults: examining social support and consolation. J. Sci. Stud. Relig. 1994;33:362–375. [Google Scholar]
  48. Kadden RM, Litt MD. The role of self-efficacy in the treatment of substance use disorders. Addict. Behav. 2011;36:1120–1126. doi: 10.1016/j.addbeh.2011.07.032. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Krentzman AR, Robinson EA, Moore BC, Kelly JF, Laudet AB, White WL, Zemore SE, Kurtz E, Strobbe S. How alcoholics anonymous (AA) and narcotics anonymous (NA) work: cross-disciplinary perspectives. Alcohol Treat. Q. 2010;29:75–84. doi: 10.1080/07347324.2011.538318. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Johansson P, Hoglend P, Hersoug A. Therapeutic alliance mediates the effect of patient expectancy in dynamic psychotherapy. Br. J. Clin. Psychol. 2011;50:283–297. doi: 10.1348/014466510X517406. [DOI] [PubMed] [Google Scholar]
  51. Laudet AB. The impact of alcoholics anonymous on other substance abuse-related twelve-step programs. Recent Dev. Alcohol. 2008;18:71–89. doi: 10.1007/978-0-387-77725-2_5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Lee CS, Longabaugh R, Baird J, Abrantes AM, Borrelli B, Stein LA, Woolard R, Nirenbert TD, Mello MJ, Becker B, Carty K, Clifford PR, Minugh PA, Gogineni A. Do patient intervention ratings predict alcohol-related consequences? Addict. Behav. 2007;32:136–141. doi: 10.1016/j.addbeh.2007.07.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Lovejoy M, Rosenblum A, Magura S, Foote J, Handelsman L, Stimmel B. Patients’ perspective on the process of change in substance abuse treatment. J. Subst. Abuse Treat. 1995;12:269–282. doi: 10.1016/0740-5472(95)00027-3. [DOI] [PubMed] [Google Scholar]
  54. Magruder KM, Ouyang B, Miller S, Tilley BC. Retention of under-represented minorities in drug abuse treatment studies. Clin Trials. 2009;6:252–260. doi: 10.1177/1740774509105224. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Magura S, Knight EL, Vogel HS, Mahmood D, Laudet AB, Rosenblum A. Mediators of effectiveness in dual-focus self-help groups. Am. J. Drug Alcohol Abuse. 2003;29:301–322. doi: 10.1081/ADA-120020514. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. McLellan AT, Hunkeler E. Patient satisfaction and outcomes in alcohol and drug abuse treatment. Psychiatr. Serv. 1998;49:573–575. doi: 10.1176/ps.49.5.573. [DOI] [PubMed] [Google Scholar]
  57. Merrick EL, Reif S, Hiatt D, Hodgkin D, Horgan CM, Ritter G. Substance abuse treatment client experience in an employed population: results of a client survey. Subst. Abuse Treat. Prev. Policy. 2012;7:4. doi: 10.1186/1747-597X-7-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Miller WR, Del Boca FK. Measurement of drinking behavior using the Form 90 family instrument. J. Stud. Alcohol Drug. 1994;12:112–118. doi: 10.15288/jsas.1994.s12.112. [DOI] [PubMed] [Google Scholar]
  59. Miller WR, Sorenson JL, Selzer JA, Bringham GS. Disseminating evidence-based practices in substance abuse treatment: a review with suggestions. J. Subst. Abuse Treat. 2006;31:25–39. doi: 10.1016/j.jsat.2006.03.005. [DOI] [PubMed] [Google Scholar]
  60. Milligan C, Nich C, Carroll K. Ethnic differences in substance abuse treatment retention, compliance and outcomes from two clinical trials. Psychiatr. Serv. 2004;55:167–173. doi: 10.1176/appi.ps.55.2.167. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Montgomery L, Burlew AK, Kosinski AS, Forcehimes AA. Motivational enhancement therapy for African American substance users: a randomized clinical trial. Cultur. Divers. Ethnic Minor. Psychol. 2011;17:357–365. doi: 10.1037/a0025437. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Montgomery L, Petry N, Carroll K. Moderating effects of race in clinical trial participation and outcomes among marijuana-dependent young adults. Drug Alcohol Depend. 2012;126:333–339. doi: 10.1016/j.drugalcdep.2012.05.033. [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Moos RH, Timko C. Outcome research on twelve-step and other self-help programs. In: Galanter M, Kleber HD, editors. Textbook of Substance Abuse Treatment. American Psychiatric Press; Washington, DC: 2008. pp. 511–521. [Google Scholar]
  64. Mulvaney-Day NE, Earl TR, Diaz-Linhart Y, Alegria M. Preferences for relational style with mental health clinicians: a qualitative comparison of African American, Latino, and Non-Latino White patients. J. Clin. Psychol. 2011;67:31–44. doi: 10.1002/jclp.20739. [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Mundt MP, Parthasarathy S, Chi FW, Sterling S, Campbell CI. 12-Step participation reduces medical use costs among adolescents with a history of alcohol and other drug treatment. Drug Alcohol Depend. 2012;126:124–130. doi: 10.1016/j.drugalcdep.2012.05.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. National Institute on Drug Abuse (NIDA) National Institute on Drug Abuse Strategic Plan on Reducing Health Disparities. NIDA Publications; 2004. Accessed 4/11/13: http://www.drugabuse.gov/pdf/healthDispPlan/pdf. [Google Scholar]
  67. National Institutes of Health (NIH) National Institutes of Health guidelines for the inclusion of women and minorities as subjects in clinical research. 2001 NIH Guide, 1994, Revised 2001. Accessed 4/11/13: http://grants.nih.gov/grants/funding/women_min/guidelines_amended_10_2001.htm.
  68. Nordfjaern T, Rundmo T, Hole R. Treatment and recovery as perceived by patient with substance addiction. J. Psychiatr. Ment. Health Nurs. 2010;17:46–64. doi: 10.1111/j.1365-2850.2009.01477.x. [DOI] [PubMed] [Google Scholar]
  69. Palmer RS, Murphy MK, Piselli A, Ball SA. Substance user treatment dropout from client and clinician perspectives: a plot study. Subst. Use Misuse. 2009;44:1021–1038. doi: 10.1080/10826080802495237. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Petry NM, Barry D, Alessi SM, Rounsaville BJ, Carroll KM. A randomized trial adapting contingency management targets based on initial abstinence status of cocaine-dependent patients. J. Consult. Clin. Psychol. 2012;80:276–285. doi: 10.1037/a0026883. [DOI] [PMC free article] [PubMed] [Google Scholar]
  71. Redmond ML, Galea S, Delva J. Examining racial/ethnic minority treatment experiences with specialty behavioral health service providers. Community Ment. Health. 2009;45:85–96. doi: 10.1007/s10597-008-9164-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  72. Reisinger HS, Schwartz RP, Mitchell SG, Peterson JA, Kelly SM, O'Grady KE, Marrari EA, Brown BS, Agar MH. Premature discharge from methadone treatment: patient perspectives. J. Psychoactive Drugs. 2009;41:285–296. doi: 10.1080/02791072.2009.10400539. [DOI] [PMC free article] [PubMed] [Google Scholar]
  73. Ryan KK, Garrett-Mayer E, Alberg AJ, Cartmell KB, Carpenter MJ. Predictors of cessation pharmacotherapy use among Black and non-Hispanic White smokers. Nicotine Tob. Res. 2011;13:645–652. doi: 10.1093/ntr/ntr051. [DOI] [PMC free article] [PubMed] [Google Scholar]
  74. Shillington A, Clapp J. Self report stability of adolescent substance abuse: are there differences for gender, ethnicity, and age. Drug Alcohol Depend. 2000;60:19–27. doi: 10.1016/s0376-8716(99)00137-4. [DOI] [PubMed] [Google Scholar]
  75. Simpson DD. A conceptual framework for drug treatment process and outcomes. J. Subst. Abuse Treat. 2004;27:99–121. doi: 10.1016/j.jsat.2004.06.001. [DOI] [PubMed] [Google Scholar]
  76. Siqueland L, Crits-Christoph P, Barber JP, Connolly Gibbons MB, Gallop R, Griffin M, Frank A, Thase ME, Luborsky L, Liese B. What aspects of treatment matter to the patient in the treatment of cocaine dependence? J. Subst. Abuse Treat. 2004;27:169–178. doi: 10.1016/j.jsat.2004.06.007. [DOI] [PubMed] [Google Scholar]
  77. Smith AH, Norton PJ, McLean CP. Client perceptions of therapy component helpfulness in group cognitive-behavioral therapy for anxiety disorders. J. Clin. Psychol. 2012;69:229–239. doi: 10.1002/jclp.21926. [DOI] [PubMed] [Google Scholar]
  78. Sobell LC, Sobell MB. Timeline Follow Back. A technique for assessing self-reported alcohol consumption. In: Litten R, Allen J, editors. Measuring Alcohol Consumption. Humana Press; New York, NY: 1992. pp. 41–72. [Google Scholar]
  79. Stein MD, Herman DS, Anderson BJ. A motivational intervention trial to reduce cocaine use. J. Subst. Abuse Treat. 2009;36:118–125. doi: 10.1016/j.jsat.2008.05.003. [DOI] [PubMed] [Google Scholar]
  80. Stout RL, Wirtz PW, Carbonari JP, Del Boca FK. Ensuring balanced distribution of prognostic factors in treatment outcomes research. J. Stud. Alcohol Drugs. 1994;12:70–75. doi: 10.15288/jsas.1994.s12.70. [DOI] [PubMed] [Google Scholar]
  81. Taylor RJ, Chatters LM, Jayakody R, Levin JS. Black and white differences in religious participation: a multi-sample comparison. J. Sci. Study Relig. 1996;35:403–410. [Google Scholar]
  82. Thompson VLS, Bazile A, Akbar M. African Americans’ perceptions of psychotherapy and psychotherapists. Prof. Psychol. Res. Pr. 2004;35:19. [Google Scholar]
  83. Thompson VL, Talley M, Caito N, Kreuter M. African American men's perceptions of factors influencing health-information seeking. Am. J. Mens Health. 2009;3:6–15. doi: 10.1177/1557988307304630. [DOI] [PubMed] [Google Scholar]
  84. Timko C, Moos RH, Finney JW, Lesar MD. Long-term outcomes of alcohol use disorders: comparing untreated individuals with those in alcoholics anonymous and formal treatment. J. Stud. Alcohol. 2000;61:529–540. doi: 10.15288/jsa.2000.61.529. [DOI] [PubMed] [Google Scholar]
  85. Tuchman E, Sarasohn MK. Implementation of an evidence-based modified therapeutic community: staff and resident perspectives. Eval. Program Plann. 2011;34:105–112. doi: 10.1016/j.evalprogplan.2010.08.001. [DOI] [PubMed] [Google Scholar]
  86. Urbanoski KA. Coerced addiction treatment: client perspectives and the impacts of their neglect. Harm Reduct. J. 2010;7:13. doi: 10.1186/1477-7517-7-13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  87. Vandevelde S, Vanderplasschen W, Broekaert E. Cultural responsiveness in substance- abuse treatment: a qualitative study using professionals’ and clients’ perspectives. Int. J. Soc. Welfare. 2003;12:221–228. [Google Scholar]
  88. Vederhus JK, Timko C, Kristensen Ø, Clausen T. The courage to change: patient perceptions of 12-step fellowships. BMC Health Serv. Res. 2011;11:339. doi: 10.1186/1472-6963-11-339. [DOI] [PMC free article] [PubMed] [Google Scholar]
  89. Waltz J, Addis ME, Koerner K, Jacobson NS. Testing the integrity of a psychotherapy protocol: assessment of adherence and competence. J. Consult. Clin. Psychol. 1993;61:620–630. doi: 10.1037//0022-006x.61.4.620. [DOI] [PubMed] [Google Scholar]
  90. Winstock AR, Lintzeris N, Lea T. “Should I stay or should I go?” Coming off methadone and buprenorphine treatment. Int. J. Drug Policy. 2011;22:77–81. doi: 10.1016/j.drugpo.2010.08.001. [DOI] [PubMed] [Google Scholar]
  91. Yerger VB, Wertz M, McGruder C, Froelicher ES, Malone RE. Nicotine replacement therapy: perceptions of African-American smokers seeking to quit. J. Natl. Med. Assoc. 2008;100:230–236. doi: 10.1016/s0027-9684(15)31211-6. [DOI] [PubMed] [Google Scholar]
  92. Zhiwei Z, Gerstein DR, Friedmann PD. Patient satisfactions and sustained outcomes of drug abuse treatment. J. Health Psychol. 2008;13:388–400. doi: 10.1177/1359105307088142. [DOI] [PMC free article] [PubMed] [Google Scholar]

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