Presentation and Progress Through the Stages of Change in Three Cohorts of Residential Substance Abuse Treatment Recipients: A Mixed-Methods Analysis

Purpose: Although extensive resources have been devoted to predicting outcomes, relatively little attention has been paid to the received content and lived experiences of clients within actual substance abuse treatment settings. Yet mounting evidence suggests that, within this “black box” of treatment, clients gather information and engage in interactions that allow them to initiate processes of change and lay foundations for new behaviors (Simpson, 2006). This mixed-methods study examined the relationship between therapeutic interactions and movement along the Transtheoretical model of stages and processes of change (Prochaska & DiClemente, 1982, 1986) among recipients of inpatient substance abuse treatment in three settings in Northern California. The over-arching purpose was to better understand how interactions (both between recipients and between recipients and staff) could contribute to instilling successful change behaviors during residential treatment.

Methods: Qualitative methods through grounded theory were utilized to produce thick descriptions via ethnographic observation at three substance abuse treatment programs. Those consisted of an inpatient, mixed-gender medical model program (N=144, average length of stay 7-10 days), as well as a men-only (N=62) and a women-only (N=32) social model residential program where clients spend an average of 2-3 months with minimal professional infrastructure (Borkman, 1984; Shaw & Borkman, 1990). All transcripts of contact generated from the abovementioned observations were then entered into NVivo to facilitate qualitative data analysis by organizing, searching, and coding data as well as generating theory. Coding occurred throughout the study in an iterative process. Open coding was followed by axial and theoretical coding (Charmaz, 2006) to discern linkages between client-client and client-staff interactions and clients' stage status. Next, those qualitative data were triangulated via t-tests and chi squares to compare clients' demographic characteristics and other categorical variables with clients' stage status across the three treatment settings.

Results: A key finding was that medical model patients bifurcated into two distinct cohorts, half of whom remained in the precontemplation stage while the rest demonstrated aspects of the preparation stage. Overall, social model recipients progressed further along the stages of change than did medical model recipients. Client-staff interactions evinced greater therapeutic benefit in the medical model, whereas client-client interactions were the primary means of treatment delivery in the social model. Lastly, peer helping hours (a ratio variable for client-client interaction) were significantly greater for male social model recipients than for females.

Implications: These findings illumine the respective benefits of client-to-client and client-to-staff interactions within the complex environments of residential substance abuse treatment. Moreover, they demonstrate the utility of the Transtheoretical model as a gauge for measuring clients' receptivity to a range of treatment interventions. Last, the findings suggest future directions for comparative research on models of treatment and the influence of gender effects in diverse substance abuse treatment settings.