Pretreatment Change in Substance Use: Implications for the Social Work Field

In the substance abuse field, as in the broader field of psychotherapy research, there is a wealth of research on behavioral change during and after treatment. By comparison, fewer studies have focused on pretreatment change. In the general psychotherapy literature, studies of pretreatment change have shown that symptom change consistently occurs after the initial phone call, when an appointment is scheduled, and before the first treatment session (e.g., Kindsvatter et al., 2010; Lawson, 1994; Ness & Murphy, 2001; Weiner-Davis et al., 1987; West et al., 2011). A similar pattern has been observed in the substance use disorder (SUD) field, with several more recent studies reporting behavioral changes occurring before the initial phone call (e.g., Stasiewicz et al., 2013; Stasiewicz et al., 2019). Although it is not typically assessed, pretreatment change is an important individual difference variable that can be used to inform adaptive treatment (i.e., person centered) approaches to improve treatment outcomes and treatment efficiency for individuals with a SUD (Petry et al., 2012).

Pretreatment change in substance use has been recognized for decades (Johnson et al., 1998; Maisto et al., 1988). Several studies have reported reductions in alcohol and drug use among a subset of individuals prior to beginning formal treatment (e.g., Morgenstern et al., 2007; Penberthy et al., 2007; Stasiewicz et al., 2019). In a randomized clinical trial investigating contingency management for cocaine abuse, a negative urine test at baseline, indicating pretreatment abstinence from cocaine, was associated with greater abstinence during and following treatment (Petry et al., 2012). Prior to initiating formal treatment for alcohol use disorder (AUD), research indicates that a substantial number of clients increase the number of days they are abstinent or reduce the number of drinks they consume on a drinking day. For example, Epstein et al. (2005) found that 44 percent of alcohol-dependent women initiating treatment achieved abstinence before the first treatment session (Epstein et al., 2005). Another study found that approximately 50 percent of adults seeking treatment for AUD demonstrated substantial changes in both quantity and frequency of alcohol consumption during the one-month period prior to the first treatment session (Stasiewicz et al., 2013). In these studies, greater pretreatment reductions in alcohol use predicted better three-month (Stasiewicz et al., 2013) and 12-month (Epstein et al., 2005) alcohol treatment outcomes. Therefore, a significant degree of change in substance use occurs after deciding to seek treatment but before formal treatment begins. These changes are maintained and enhanced over the course of treatment.

Application to Social Work Practice, Research, and Policy

The assessment and identification of pretreatment change in substance use align well with solution-focused and other strengths-based approaches in the social work field and offer several useful directions for social work practice. For example, the knowledge that pretreatment change has occurred may be of value to clinicians in identifying and capitalizing on client strengths and resources, enhancing self-efficacy for change, and helping clients maintain pretreatment gains (Stasiewicz et al., 2019). The assessment of pretreatment change also aligns with social work best practices that utilize a collaborative approach to formulating treatment goals with clients that build on and reinforce positive steps taken. Solution-focused treatment, which has been extended to SUD treatment (e.g., Berg & Miller, 1992; de Shazer & Isebaert, 2004), can complement other SUD interventions such as brief motivational interventions and cognitive–behavioral therapy. Similar to what is seen in mental health–focused interventions structured around a solution-focused approach, clinicians can assess for pretreatment behavioral changes and frame them as evidence that clients have already initiated behavior change. Depending on what a client wants to accomplish, demonstrating pretreatment change may be well on their way toward achieving their treatment goals. To enhance gains associated with pretreatment change, clinicians can strengthen existing positive behaviors and work collaboratively with clients to adopt new behaviors to support sustained recovery from SUD.

Awareness of pretreatment change may also inform clinical research and organizational policies. As an individual characteristic, pretreatment change can be used to determine initial treatment decisions in clinical trials investigating adaptive treatment approaches (e.g., Petry et al., 2012). For instance, a person who demonstrates greater pretreatment change in drinking may benefit from treatment that is less intensive, shorter in duration, or places greater emphasis on relapse prevention. Clinical research aimed at establishing the predictive value of pretreatment change has great appeal in settings where a premium is placed on the efficiency with which clinicians are able to make decisions regarding appropriate treatment assignment or duration. Importantly, results from such studies have the potential to simultaneously conserve resources and improve treatment outcomes. When clients are provided services that match their needs, SUD treatment may be a more efficient use of provider and healthcare resources. For example, less intensive interventions can be provided to those who demonstrate substantial pretreatment improvement and fewer barriers to change, thus helping to maximize clinical resources in mental health and SUD agencies (Stasiewicz et al., 2019).

Conclusion

Pretreatment change in substance use has implications for improving treatment, research, and more efficient allocation of healthcare resources. Recent findings emphasize the importance of adapting treatment for those who demonstrate pretreatment change in substance use, potentially resulting in improved treatment efficiency and effectiveness. For social work practitioners, awareness of the phenomenon can ignite strengths-based approaches to create a climate of optimism, hope, and the possibility of a successful recovery.

 

Charles LaBarre, MSW, is a PhD student, School of Social Work, University at Buffalo, 1021 Main Street, Buffalo, NY 14203, USA; email: clabarre@buffalo.edu.

Paul R. Stasiewicz, PhD, is professor and Janet B. Wattles endowed chair; Braden K. Linn, PhD, LMSW, is visiting professor; and

Clara M. Bradizza, PhD, is professor, School of Social Work, University at Buffalo, Buffalo, NY, USA.

 

Research reported in this publication was supported by the U.S. National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH) under Award Number R01AA022080, R01AA023179, and T32AA007583 to the University at Buffalo. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.