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Using 53 studies, comprising 52 separate data sets, published in refereed journals from 1985 through 2006, the authors conducted meta-analyses of the correlation and mean difference between client–therapist alliance ratings. Client and therapist alliance ratings were moderately correlated ( =.36, SD=.00); clients’ ratings were higher than ratings by their therapists ( =.63, SD=.42). Client disturbance was a significant moderator of client–therapist alliance rating discrepancies; clients with milder disturbances or with substance abuse problems tended to have larger rating discrepancies with their therapists than clients with more severe disturbances or moderate disturbance without substance abuse.

Although a large number of job-ready welfare recipients have left welfare since the enactment of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P. L. 104-193-PRWORA), 5.5 million “harder-to-serve” populations including those with substance abuse problems still remain in state TANF caseloads. Although researchers and policy makers need to better understand the connections between substance abuse and welfare dependency, little is known about states' response to substance-abusing TANF recipients. This review of state TANF policies on substance abuse found that few states have developed systematic procedures for assessment, evaluation, and treatment of substance abuse among welfare recipients. Implications for policy are discussed.

This paper uses data from the National Study of Protective, Preventive, and Reunification Services Delivered to Children and Their Families, 1994 to estimate the effects of several indicators of poverty and parental characteristics associated with substantiated physical neglect. Results suggest there is a high correlation between substantiated physical neglect and several indicators of poverty (i.e. AFDC, food stamps, Medicaid, unemployment, and WIC). After controlling for family characteristics in a logistic regression, those indicators of poverty were not found to be predictive of substantiated physical neglect. Only WIC recipients had an association, and they were less likely to have physical neglect substantiated. The two strongest predictors of physical neglect were related to primary caretakers who were twice as likely to have physical neglect substantiated if they had mental health or substance abuse problems.

Few effective methods of intervention exist for youth at risk for negative life outcomes. One method used successfully with both adults with chronic mental illness and adults with substance abuse problems is strengths-based case management (SBCM). Based on the principles of strengths theory, SBCM aims to assist individuals in identifying and achieving personal goals, with an emphasis on the case manager–client relationship and client self-determination. In the current study, the authors report findings from a feasibility study that implemented SBCM with adolescent runaways. Challenges to implementation, such as financial status, the role of families, abuse and neglect, developmental issues, education, peer relationships, and transportation, are examined. The current findings suggest that it is feasible to successfully implement SBCM with adolescents, but the challenges to application are different with this group compared with adults, given the developmental differences between adolescents and adults.

Objetivos: O Sistema de Avaliação da Mudança Narrativa (SAMN) caracteriza e avalia as narrativas e as suas mudanças na terapia em sete dimensões: singularidades (A), natureza da história (B) conotação narrativa (C), relato da história (D), reflexividade narrativa (E), temas da sessão (F) e comportamentos alternativos (G). Método: O SAMN foi aplicado em 83 sessões para testar a sua fidelidade e validade: 22 sessões em terapia familiar sistémica devido a abuso de substâncias (estudo 1); 15 sessões de terapia familiar e de casal devido a vários problemas (estudo 2) e 46 sessões de terapia familiar devido a negligência parental, com 18 famílias consideradas clientes involuntários. Resultados: A fidelidade estimada do SAMN (Kappa de Cohen) variou entre excelente e satisfatória. A validade do SAMN ficou estabelecida pela deteção e avaliação da narrativa em problemas distintos e modalidades de terapia sistémica (familiar e de casal). Conclusões: As singularidades, reflexividade narrativa e a mudança nos temas da sessão (para temas que não o problema) foram as dimensões que mais sofreram alterações na maioria dos casos de sucesso comparativamente com os insucessos. / Aims: The Assessment System of Narrative Change (ASNC) characterizes and evaluates narratives and their changes in therapy, across seven dimensions: singularities (A), nature of the story (B), narrative connotation (C), telling of the story (D), narrative reflexivity (E), session themes (F) and alternative behaviors (G). Method: The ASNC was applied in 83 sessions to evaluate its reliability and validity: 22 sessions of systemic family therapy related to substance abuse problems (study 1), 15 sessions of couple and family therapy related to several different problems (study 2) and 46 sessions of family therapy related to parental neglect, with 18 non-voluntary families (study 3). Results: The estimated reliability of the ASNC (Cohen’s Kappa) varies between excellent and satisfactory. The validity of the ASNC was established through its accuracy in the narrative evaluation of different problems and therapeutic modalities (family and couple therapy). Conclusions: Singularities, narrative reflexivity and the change in session themes (to nonproblematic themes) were the dimensions that changed the most in cases with good outcomes compared to those with poor outcomes.

Juvenile justice systems in the United States do not always respond effectively to substance abuse problems among young offenders. In 2002, the Robert Wood Johnson Foundation launched a 10-community demonstration project to address this problem. Reclaiming Futures (RF) relies on community partnerships to improve treatment quality, strengthen local leadership, expand inter-organizational collaboration, and create systems of shared performance management. The initial findings of a cross-site evaluation suggest that Reclaiming Futures is yielding important and positive change. Bi-annual surveys of key informants measure the quality and integration of juvenile justice and substance abuse treatment systems in each community. Of 13 indices measured by the surveys, 11 showed significant improvements between 2003 and 2005.

This study examined the relationship between disability payment status and clinical outcomes among 305 homeless veterans entering VA treatment. Disability status and clinical outcomes were characterized using self-report data at program entry, and quarterly for 2 years thereafter. Seeking or already receiving disability benefits at program entry was not associated with any of the 8 clinical outcomes examined. Those seeking or receiving disability benefits during the 2 years that followed showed more serious mental health problems and lower levels of mental health functioning, but no greater risk of substance use or not being employed nor worse housing outcomes than those who remained uninterested in applying for disability benefits. This study does not, therefore, support the notion that disability orientation results in poorer clinical outcomes, at least not among homeless veterans.

Substance abuse among patients with schizophrenia is quite common, with at least half of these individuals having a lifetime diagnosis of a substance abuse disorder. These so called ‘‘dual diagnosis’’ or ‘‘co-occurring disorder’’ patients have an increased utilization of medical and psychiatric services.Theyare more difficult totreatand usually have a worse prognosis as compared with nonsubstance abusing patients with schizophrenia. Fortunately, in recent years, the treatment of dually diagnosed patients has significantly improved. It has been established that the best treatment of these patients includes enrollment in an integrated program that treats both mental illness and substance abuse problems simultaneously. Previously, we published an article that reviewed the available psychopharmacological options for treatment of co-occurring disorder patients. This article will focus more on the psychosocial treatment modalities that have been used to reduce the psychiatric morbidity and substance relapse in these patients.

As a safety net, psychiatric emergency services are sensitive to system changes. To determine the impact of a state's changes in its mental health system, administrators of publicly funded psychiatric emergency services were surveyed. They reported few (M=0.8) negative changes in coordination of care but 77% endorsed change in administrative burden (54% saying it negatively affected quality of services). Reporting negative effect of administrative burden was associated with treating more persons with substance abuse problems and greater challenge posed by distance to local providers. These results suggest that impact of state-level changes was not uniform but associated with local characteristics.

Illegal drug use remains one of the United States' most serious health problems, and the “War on Drugs” continues without an end in sight. Antidrug programs, which offer the potential to reduce substance abuse problems, are a component of efforts to deal with the problem, but they operate absent adequate scientific analysis. Although policy has shifted from a focus on supply control to one that includes prevention and treatment, research and theory lag behind program implementation. Thus, for example, community-based programs designed to change norms and systems of substance use have been widely promoted despite the lack of data to support their use. The present paper summarizes findings from an evaluation of a large national demonstration program, “Fighting Back.” Results of the evaluation of broad-based community initiatives in a dozen communities show that the programs failed to reduce rates of substance use and associated harms. These findings, along with other evidence, place reliance on community-based programs at odds with public rhetoric. To deal more effectively with substance abuse, there is a need to move from “grading” programs to understanding why and how interventions function.

This article discusses research documenting the negative effects of stress during law school.These effects include decreases in law students' emotional and psychological health, development of substance abuse problems, and impairment of the ability to learn.Personality type, moral reasoning, motivation, and learning style are also linked to the ability to cope with the stress of law school.Recommendations are made for changes in legal education which emphasize student differences and needs in an effort to decrease stress, improve psychological and emotional health, and increase learning.

In order to assess the prevalence of mental health and substance abuse among youth in one state’s juvenile justice facilities, a survey was conducted of 40 Tennessee facilities. A total of 1215 youth were being held on the “one day census” that was taken as part of the survey. The survey documented many mental health and substance abuse issues: 1) 53 percent of the youth in juvenile justice facilities were experiencing mental health problems; 2) 15 percent were taking some type of psychiatric medicine while in the juvenile justice facility; 3) 42 percent were known to have substance abuse problems; and 4) 30 percent had co-occurring mental health and substance use problems. Policy and program recommendations based on these findings are discussed.

SUMMARY A review of the epidemiology of substance abuse and corollary treatment capabilities for older adults is summarized. This review demonstrates that there is a growing number of older adults with substance abuse problems, and that a majority of such adults are under-diagnosed and have little access to treatment. Research at Odyssey House, a non-profit, substance abuse and mental health treatment agency based in New York City, where older adults have been treated since 1997 within a discrete residential unit, is reviewed. Findings identify two distinct subgroups among the older adults being treated at Odyssey House: lifelong users (become dependent on drugs during adolescence) and late-in-life users (become dependent on drugs after age 45). Treatment implications are discussed in terms of the provision of special groups, such as trauma and bereavement groups for late-in-life users; and poly-substance abuse and relapse prevention groups for the lifelong users. The Enhanced Therapeutic Community is pre...

This study examines the effect of previous participation in time limited residential treatment and other factors on treatment outcomes among homeless veterans with serious mental illness placed into permanent supported housing. The sample consisted of 655 veterans placed into supported housing at 18 sites through the VA's Healthcare for Homeless Veterans (HCHV) Supported Housing Program during the period 1993-2000. Data on client and program characteristics, and treatment outcomes, were documented by HCHV case managers staffing these programs. Data on use of VA services, including time limited residential treatment received 6 months prior to entry into supported housing, were extracted from VA administrative files. The relationship of prior residential treatment, as well as other measures of client characteristics, service use, and program characteristics, to outcomes were assessed using both bivariate and multivariate Cox proportional hazards regression and logistic regression. After adjusting for client characteristics, service use, and program characteristics, no differences in outcomes were found between clients who had received prior residential treatment and those placed directly into permanent supported housing. Prior residential treatment appears to have little effect on treatment outcomes among formerly homeless veterans placed into permanent supported housing programs providing indirect support for the direct placement supported housing model.

A random sample of 632 female head of household welfare recipients in two California counties was interviewed three times in the period between 1999 and 2001 to assess the correlates of substance abuse. Results suggest that a need for substance abuse services is associated with going on and off welfare more than once, leaving welfare for negative reasons, failing to find employment, and a low trajectory of earned income. These findings suggest that welfare administrators might usefully work with substance abuse providers to identify and serve welfare recipients with substance abuse problems.

This article introduces a combination of approaches based on multicultural interventions and sociopolitical themes that provide interventions for working with Latinos with substance abuse problems.

Treatment Alternatives to Street Crime (TASC) is a national program model that has been proposed as a strategy to address the needs of offenders with substance abuse problems who are under some form of community corrections supervision. Logistic regression analysis of a random subsection of 300 clients discharged from a Northwest Ohio TASC program during calendar year 2000 found that successful completion of TASC was significantly associated with a reduction in rearrest within 12 months following TASC discharge. This effect was seen even after controlling for other factors associated with criminal recidivism, such as age, sex, prior criminal history, and prior alcohol and drug use.

This article aims to inform evaluators about issues involved in using and integrating administrative databases from public agencies. With the growing focus on monitoring and oversight of public programs for health, mental health and substance abuse problems, existing data sets in public agencies became an important source of evaluation and planning information. The focus of this article is on the methods used to find, integrate and analyze multiple existing databases. Primary challenges that confront the evaluator in identifying and accessing data sources and in addressing the technical issues involved are discussed.

The main objective of this study was to compare symptom load and lifetime treatment experiences between psychotic patients with substance abuse problems and psychotic patients without substance abuse problems. This is a cross-sectional study of 48 patients (26 inpatients and 22 outpatients) in a clinic for early intervention in psychosis. Patients' were grouped into two categories based on whether they had a substance abuse problem or not. Twenty-one (43.8%) had a substance abuse problem and 27 (56.2%) had not. We used the Positive and Negative Symptom Scale (PANSS) scale to measure symptoms and several scales to measure substance abuse. Parametric tests (independent t-tests) were used to compare continuous variables, and chi-square tests were used to compare frequencies. Positive symptoms, negative symptoms, general psychopathology symptoms and the total score of psychotic symptoms did not differ significantly between the groups with psychosis alone and psychosis with substance abuse. The delusion subscore was significantly higher in the group with psychosis alone (t = -2.3, df = 41, P0.05), and the anxiety subscore was significantly higher in the group with psychosis with substance abuse (t = -2.3, df = 41, P0.05). There were no significant differences in the subscores for negative symptoms. The absence of differences in psychotic symptoms between the two groups with psychosis does not imply a strong relationship between psychotic symptoms and substance abuse. These results do not support the self-medication hypothesis. The higher rates of institutionalization among substance abusers may be explained by mechanisms other than exacerbations of psychotic symptoms, as there are few differences in symptoms among abusers and non-abusers.

The purpose of the current study was to examine differences in responses of older adults (age 55 and above) and younger adults (ages 18 to 54) to the Drug Abuse Problem Assessment for Primary Care (DAPA-PC), a computerized drug and alcohol abuse screening instrument developed for primary care settings. Data were collected from a diverse population of 327 adults presenting for care at The George Washington University Medical Faculty Associates clinic in downtown Washington, DC. Results indicated that rates of drug and alcohol abuse were similar in both groups. However, older adults were less likely than younger adults to perceive their drug use as problematic. This finding has serious implications for older adults, who tend to be underrepresented in treatment programs. There is a need for screening seniors and identifying those who may be at risk for substance abuse problems. Differences in responses to alcohol and drug assessments by age should be taken into consideration when designing screening instruments. The results of this study suggest that the DAPA-PC would provide a useful instrument for screening older adults in a primary care setting.

In this article, we explore how alcohol and drugs enter into the lives of welfare clients, affecting the ways by which they leave welfare. Our analysis draws on clients’ narrative accounts of circumstances surrounding their welfare exits. We find that substance abuse by clients or by those close to them can interfere with individual functioning and shape clients’ interactions with social networks and public agencies. This, in turn, may result in conflicts and trade‐offs that bear directly on welfare eligibility. Our findings suggest the need for welfare approaches that address the complexity of substance abuse problems.

In this article, the author analyzes the issues and standards facing mental health counselors (MHCs) when working with lesbians and gay men who have substance abuse problems. In order to provide professional and affirmative services to clients from this population, it is critical for MHCs to understand the social and historical context of the lives of lesbians and gay men. Therefore, some of the major factors that contribute to substance abuse problems in the gay community are explored. Finally, guidelines regarding legal protections for this population are provided.

This study outlines the treatment needs of women offenders entering prison-based therapeutic communities, known as institutional therapeutic communities (ITCs). Intake data for 4,509 women and 3,595 men from 15 ITCs were compared. Results show that men and women entering prison treatment differ with regard to their substance abuse problems, psychological functioning, sexual/physical abuse histories, employment histories, and child support activity. Women have more severe drug use histories and psychological impairment, were more likely to use prescription drugs, and to report histories of sexual/physical abuse. Men were more likely to have been employed, completed high school, and to plan to support their children upon release. It appears that women entering treatment programs in state prisons are at a substantial disadvantage compared with their male counterparts.

Objective: This study examined the effects of a collaborative intervention targeting 107 juvenile detainees with co-occurring mental health and substance abuse problems. Method: Changes in mental health problems, substance use, and delinquency between pretest and 3-and 6-month follow-up were assessed. Three distinct clusters of detained youth characterized by varying levels of self-reported symptoms and behaviors across these three problem domains were included in a series of repeated measures analyses. Results: Significant time effects were found for anxiety and depression and for the frequency of substance use and delinquency between pretest and 3- and 6-month follow-up. Significant time by cluster interactions were found for mental health problems of obsessive-compulsive behavior and interpersonal sensitivity and for property and drug-related offending. Conclusions: Cross-system collaboration among mental health, substance abuse, and juvenile justice systems is a promising approach for treating delinquent youth with co-occurring problem behaviors.

As scholars of local corrections have noted, jails hold a myriad of inmates for widely diverse reasons. What remains unclear, however, is what purpose or purposes jails are expected to serve. Despite considerable research on the degree of support for various correctional goals, little is known about what goals people want local jails to pursue. Using a survey of local criminal justice leaders in Orange County, Florida, this study examines the preferences policy makers hold regarding the appropriate functions of jails. Our results suggest that these policy makers supported several utilitarian goals but were most supportive of rehabilitation and serving the needs of those with mental health and substance abuse problems. Lesser support was expressed for incapacitation, deterrence, retribution, and detention. The implications of these findings for criminal justice policy and for future research are discussed.

Mental health and substance abuse problems impose significant direct and indirect costs on society, yet an increasing number of effective preventive interventions have been identified in the field of behavioral health. Using the Institute of Medicine's “Continuum of Care” model of prevention, we examine the evolution and future prospects of prevention in the managed care environment. Specific barriers and opportunities for expanding prevention efforts are discussed.

While substance user service programs can help homeless adults solve their substance use and housing problems, relatively few needy individuals use and complete these programs. The lack of participation is poorly explained by typical empirical studies, most of which consider the role in service participation of various personal traits and client problems. The current article instead seeks to explain service participation through the application of an alternative, "socio-rational choice" model. This model has three premises: Clients weigh the costs and benefits of participating in services against alternative uses of their time and resources. The clients' weighing procedures reflect their personal situations and perceptions of the treatment environment. The perceptions of their personal situations and perceptions of the treatment environment are affected by the manner in which clients react to representatives of service systems, members of their social network including both housed and homeless persons, and other individuals. Secondary evidence supports many of the model's hypotheses and generally suggests that homeless clients may be heavily affected by their experiences with individuals and systems with which they come into contact.

Many states are now moving toward enrolling Medicaid recipients into managed care programs. This presents both opportunities and challenges to providers treating individuals with personal adjustment and/or substance abuse problems. A comparative research design was used to describe two groups of low-income women in Houston, Texas: 133 chronic drug users and 381 non-drug users. Participants were administered the Multidimensional Addictions and Personality Profile (MAPP) in order to measure personal adjustment and substance abuse problems. The results show that while many of the nonusers in the sample may only require moderate outpatient services, a substantial proportion of drug-using women (31%) required inpatient hospitalization for personal adjustment or substance abuse problems. An additional 12% of drug users had substance abuse problems or personal adjustment problems sufficient for referral to in-hospital treatment with substantial structured aftercare. We endorse a multidimensional approach in providing services to low-income individuals within a managed care setting.

Previous reports have indicated that a high percentage of those responding to advertisements for healthy controls for psychiatric research have personal or family histories of illness which would exclude them from such studies. We reviewed 1757 telephone screen interviews conducted over 14 years to determine: (1) the effectiveness of a screen for excluding unhealthy volunteers, (2) whether the reasons for exclusion changed over time, and (3) the final yield of healthy participants for psychiatric research after taking account of exclusions from telephone screens, no-shows and exclusions identified by direct interviews. Volunteers for psychiatric research, solicited by 43 newspaper advertisements in the Baltimore metropolitan area from 1989-2002, were initially screened by telephone and scheduled for in-person interviews if no exclusions were identified at the initial screen. More than half of the telephone respondents had major medical illnesses, substance abuse problems, depression, an Axis I disorder (not depression), a relative with a psychotic disorder or were otherwise deemed not eligible for face-to-face interview. Of the telephone respondents scheduled for direct interviews, 29% did not show up. However, the respondents who completed the direct interviews had a high likelihood of inclusion as non-ill controls for psychiatric research studies. Since Axis I and II interviews and family history take approximately 4-5 h per subject, the telephone screen is a cost-effective initial step in identifying healthy controls for psychiatric research.

This article describes groups at two residential settings for women with substance abuse problems, a shelter and a drug treatment center. The groups employed meditation exercises and cognitive restructuring techniques to teach meditation and relaxation, to help members identify and correct distortions causing stress, to provide positive and credible countering thoughts, and to improve social relationships. The groups and the themes that arose are described and examples are presented.

In this report we provide an overview of research on the voucher-based incentives approach to substance abuse treatment. This approach was originally developed as a novel method for improving retention and increasing cocaine abstinence among cocaine-dependent outpatients. The efficacy of vouchers for those purposes is now well established, and plans are underway to move the intervention into effectiveness testing in community clinics. The use of vouchers also has been extended to the treatment of alcohol, marijuana, nicotine, and opioid dependence. Particularly noteworthy is that vouchers hold promise as an efficacious intervention with special populations of substance abusers, including pregnant and recently postpartum women, adolescents, and those with serious mental illness. Overall, voucher-based incentives hold promise as an innovative treatment intervention that has efficacy across a wide range of substance abuse problems and populations.

The author examined correlates of social support among 101 offenders in corrections-based treatment programs. Respondents perceived high levels of support despite numerous interpersonal problems. Social support was significantly associated with visits, letters, arrests, and days in treatment (p < .05). The author describes strategies for implementing family-oriented interventions in corrections-based programs.

This final paper of our five-part series utilizes the treatment of substance abuse problems as a paradigm of ways in which residential programs can help adolescents negotiate the transition into the community in a gradual, systematic manner. It considers a range of community resources available to adolescents with chemical dependency problems, ways in which these resources can be incorporated into residential treatment, and their use in different stages of the treatment process.

A large percentage of jail inmates suffer from substance abuse problems; however, providing treatment in jail is difficult. Multnomah County's In Jail Intervention Program (IJIP) demonstrated an effective alternative. Finigan, Barron, and Carey (In press) and Barron and Finigan (1999) demonstrated that inmates with substance use problems, especially women, participating in IJIP experienced fewer rearrests and reincarcerations. To address the question of what led to these outcomes, quantitative data were abstracted from program, jail, and state administrative databases and were supplemented by face-to-face interviews with key informants, including program participants and former participants. In addition to their substance abuse problems, IJIP participants were chronic offenders who were more likely to be diagnosed with mental health problems. Results suggest that treatment preparation together with coordination of jail release and entry to treatment increased numbers enrolling in treatment and helped former inmates engage in treatment more quickly. Quantitative data suggest that the longer inmates stayed in IJIP, the more likely was completion of community treatment.

IntroductionDifferences between the most frequently reported diagnoses of Greek people and immigrants in Greece are expected due to the different underlying factors which are associated with mental health issues.ObjectivesExamine differences in diagnoses between Greek people and immigrants.AimsTo investigate whether Greek people and immigrants had significant differences with regard to reported diagnoses in a Greek hospital.MethodsThe patients who participated in this study are 5551, among them 2760 (49.7%) were males and 2791 (50.3%) were females. The mean age of the sample was 45.54. The sample consisted of 455 (8.3%) immigrants and 5,042 (91.7%) Greek people. Convenience sampling method was used and the sample was collected at the General Hospital of Nikaia, “Ag. Panteleimon” in Athens, Greece, between 01/01/2012 and 31/12/2015.ResultsThere were significant differences between Greek people and immigrant with regard to diagnosis as χ2 (20): 136.875, P < 0.001. More specifically, among Greek people, the most frequently reported diagnosis was psychotic disorder (26.2%), followed by depression (24.7%), general anxiety disorder (9.9%) and substance abuse (8.4%). Among immigrants, the most frequently reported diagnosis was psychotic disorder (22.9%), followed by substance abuse (21.3%), depression (17.4%) and general anxiety disorder (12.1%).ConclusionsThe differences between Greek people and immigrants with regard to diagnoses showcase the different needs between the two populations with regard to mental health. Especially, the higher prevalence of anxiety disorders and substance abuse problems among immigrants highlight the need for protective measures to improve their well-being and reduce their risk of mental health issues.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Purpose: Among marijuana-dependent individuals, approximately 50% smoke tobacco. These individuals are exposed to increased risks of respiratory and other health problems. The current study examined whether tobacco smoking among marijuana-dependent individuals is also associated with increased psychosocial and substance abuse problems. Methods: Marijuana-dependent individuals ( N =174) seeking treatment for marijuana problems completed a 2–3 h assessment. Current tobacco smokers were compared to ex-smokers and never smokers on demographic, psychosocial, and substance use characteristics, and treatment outcome. In addition to univariate comparisons, multivariate analyses using multinomial logistic regression were conducted to control for the correlated nature of the predictor variables. Results: Current tobacco smokers earned less income and reported histories of more alcohol problems than never smokers and had fewer years of education, more legal problems, more psychiatric symptoms, and an earlier age of marijuana initiation than ex- and never smokers. Over the course of treatment, current tobacco smokers had significantly fewer marijuana-negative urine specimens and fewer weeks of continuous marijuana abstinence than ex-smokers. Implications: Current tobacco smokers appear to represent a subgroup of marijuana-dependent individuals who have increased psychosocial problems compared to ex- and never smokers and may not respond as well to treatment than ex-smokers.

Day reporting centers have developed as an important approach to providing treatment and rehabilitation opportunities. This exploratory study first examined rearrest among clients in two day reporting centers that serve high risk/high need probationers with substance abuse problems. Logistic regression models indicated that completion of the DRC program was associated with a lower chance of rearrest. Next, models compared DRC clients to two comparison groups of probationers. Rearrest was related to the commonly found personal characteristics of age, offense, and prior record, rather than factors important to DRC program participation. Because of the small sample sizes and exploratory nature of the study, the results are suggestive and impressionistic rather than definitive.

The article is concerned with the way that a 12-step treatment programme construes a certain kind of image of its clients and their substance abuse problems. The main focus is on how the basic assumptions of the treatment programme are reproduced and maintained at the weekly meetings of the multiprofessional team running the programme. The article offers a behind-the-scenes look at the 12-step treatment programme: in particular, we are interested in the ways that the staff process and use the background information available on the clients admitted. We want to know how the methods and approaches used by the multiprofessional team shape and influence the kind of treatment that the clients will receive. Based originally on the AA recovery programme, the 12-step treatment programme draws on the disease concept of alcoholism. One of our main observations is that this disease concept is conducive to selective and purposive working methods in the programme. Information on the patients' background or their test results are systematically so interpreted that the outcome confirms the view that the clients are indeed alcoholics who can only be treated by methods that are consistent with the programme ideology. Strict normative expectations are placed upon clients in the programme, and any sign of deviation will be interpreted as resistance and reluctance on the part of substance abusers to deal with their own alcohol problems. In this way the programme itself may produce resistance among clients and the staff may easily elicit the resistance and denial that they regard as symptoms of alcoholism. A key focus in the article is on the interactive techniques and tactics applied in the programme to construe clients' alcohol problems in a manner that fits in with the institution's treatment culture. These techniques and tactics are studied using the methods of conversation analysis. The material consists of videorecordings from seven staff meetings in spring 1997, which have been transcribed in line with CA conventions. The focus of our analysis is not on spoken interaction, but we are chiefly interested in demonstrating how the institutional beliefs and values of the treatment programme determine the interactive planning of treatments.

Attrition in male battering treatment programs is a serious problem. To keep clients in treatment, it is crucial to understand why they drop out. The current study examined the contribution of both client and program characteristics in predicting dropout from treatment programs for abusive men. Data were collected at intake from 306 abusive men who sought treatment at four different sites. The rate of preprogram attrition (from intake to the first treatment session) was higher in the program that had a lengthy waiting list (46%) than in the other programs amp lpar3%-13%). In-program attrition was more highly related to client characteristics than program characteristics (all programs had rates between 36% and 42%). Those men who dropped out after starting treatment tended to have unstable lifestyles (e.g., substance abuse problems, criminal history, unemployment) and to have inflicted more severe abuse than those who completed treatment. Results also supported a significant interaction between verbal aptitude and structure of program; men with low verbal aptitude were the most likely to drop out of an unstructured program. Possible strategies for preventing attrition are discussed.

This proceedings consists of five papers presented at a conference titled: Psychosocial Issues and Problems of Co-Morbidity for Native American Clients with Substance Abuse Problems. The conference was held June 2-4, 1999, in Albuquerque New Mexico, and was hosted by the Native American Research and Training Center (NARTC) and the National Center for American Indian and Alaska Native Mental Health Research.

Benzodiazepines are probably prescribed too often to people with substance abuse problems. The drugs often alleviate symptoms effectively on a short term, but pharmacodynamic interactions and development of dependence cause problems. Indistinct, but important side effects might be overlooked or misunderstood. Evidence-based practice should replace prescriptions based on unclear indications.

To assess the role of toxicologic detection of alcohol to diagnose substance abuse disorders in suicides, the author reviewed suicide studies with both comprehensive toxicologic and diagnostic data. The sensitivity of alcohol detection to diagnose alcohol and substance abuse disorders in suicides was low in all studies (range, 39%-42%), and the specificity was 80%-95%. A higher cutoff level for alcohol did not increase diagnostic performance. The author concludes that toxicologic detection of alcohol is not a reliable indicator of alcohol and substance abuse disorders in suicides because of the high rate of false-negatives. Most of the suicides with positive alcohol detection seem to suffer from chronic substance abuse problems. The role of intoxication is difficult to assess because of methodologic problems.

Using secondary analysis, this study compared the characteristics of 1,763 parolees with substance abuse problems who successfully completed a post incarceration drug treatment program with those who did not. Those who completed the program were more likely to be women who had not used drugs 30 days before program admission, had fewer prior treatment experiences, remained in the program longer, and had secured employment and stable living arrangements by the time of discharge. Implications for treatment and program development are discussed.

The highest incidence of TBI is among young adult males who also have the highest incidence of substance abuse [1]. Since these individuals have long life expectancies, it is important that they are productive post injury; however, the employment rate is extremely low. This is understandable, given the fact that a person with either a TBI or substance abuse disorder would have difficulties with work. Naturally, the combination of the two compounds the problem and further complicates matters. This article provides an overview of how a Supported Employment approach can be used to assist persons with a TBI and substance abuse problems with returning to work.

A substantial body of recent research has focused on the prevalence of substance abuse among pregnant women, Its effects on maternal and infant health, ways to identify and effectively treat pregnant women, and the cost of care for pregnant women and their infants. However, this research has been hampered by a lack of data, particularly at the state and local levels. The potential benefits of such research for improving treatment and other services to this high-risk group make it important to continue to develop accurate and timely data sources. This study builds on previous work that investigated the quality of birth certificate and Medicaid data as well as previous efforts to merge these two data sources by augmenting the merged birth certificates and Medicaid data with data on a group of known substance abusers - those in substance abuse treatment. The purpose of merging these records is to improve the identification of pregnant substance abusers and, more importantly, to provide an enriched data source of variables from all three sources. Using merged data from two example states, we show that linked birth certificates, Medicaid claims, and state substance abuse treatment files provide a useful source of information for studying the birth outcomes and costs for pregnant women in substance abuse treatment. However, certain groups, such as women who do not obtain any health care or substance abuse treatment, will be underrepresented in such a database. Consequently, efforts at more complete surveillance of pregnant substance abusers should be undertaken, perhaps through increased efforts to improve reporting on the birth certificate, which is a universal document.

We surveyed 62 school administrators from three midatlantic (MD, VA, WV) and one northeastern (CT) state on factors relevant to developing school-based mental health programs. Administrators were from schools that varied on education level (elementary, middle, and high) and geographic location (urban, suburban, and rural), with equivalent numbers in each subgroup. Administrators provided ratings to questions grouped in five categories: (a) Stressful Conditions, (b) Internalizing Behavioral Problems, (c) Externalizing Behavioral Problems, (d) Substance Abuse, and (e) Barriers to Mental Health Care, and provided open-ended comments on needs of youth and mental health programs for them. They rated behavioral and substance abuse problems as progressively more serious as students advanced in school level. Urban youth were reported to encounter higher stress and present more severe internalizing problems than suburban or rural youth. Suburban and rural schools provided more health and mental health services than urban schools. Across geographic locales, physical health services far outnumbered mental health services. Findings related to barriers to mental health care, and the viability of schools as delivery sites for comprehensive mental health services, are discussed.

As investor-owned organizations increase their presence in the mental health care sector, questions emerge regarding the effects of ownership type on service delivery. One important question is whether ownership is related to patient access to care for persons requiring treatment for substance abuse problems. Using data from a 1995 national survey of outpatient substance abuse treatment units, the authors investigate whether there are differences in measures of patient access to care among investor-owned, not-for-profit, and public provider organizations. Results indicate investor-owned units cater to and serve a clientele that differs from that of not-for-profit and public units, suggesting the presence of a two-tiered system of substance abuse treatment.

Substance abuse is a serious concern in the profession of nursing. The American Nurses Association (1997) estimates that 10% to 20% of nurses have substance abuse problems, and that 6% to 8% of registered nurses are impaired due to their abuse of alcohol and other drugs. Chemical dependency is considered a disease that requires treatment. Early identification and treatment of the chemically dependent nurse is important for the safety of the public and for the well-being of the nurse and her profession. This article addresses substance abuse from a biopsychosocial perspective, and includes a description of an approach to treatment and suggestions for the role of nursing administration.