46..64
T. N O R D F J R N 1 m s c p h d - c a n d . , T. R U N D M O 2 d r. p h i l o s . &
R. HOLE3 cand.psychol.
1
Research Scientist, 3Profession Manager, The Drug and Alcohol Treatment in Central Norway, Strandveien 1,
Stjrdalen, and 2Professor, The Norwegian University of Science and Technology, Department of Psychology,
Trondheim, Norway
Accessible summary
Correspondence:
T. Nordfjrn
7415 Trondheim
Norway
E-mail: trond.nordfjern@rus-midt.no
Abstract
Social relations to therapists and other patients in treatment are important for
positive and negative experiences among patients with substance addiction.
Improvements in mental health and substance use were considered as the more
important areas of recovery among these patients.
One of the core reasons for premature dropout could be a failure to establish
positive social relations and temptations to relapse to substance use.
Research concerning patients with substance addiction and how they perceive their
treatment remains scant. The objective of this study was therefore to examine positive
and negative perceptions of treatment and recovery from the perspectives of these
patients. Data were collected with semi-structured interviews among seven patients
who completed treatment and six patients who prematurely dropped out from their
programme (n = 13). Patients were strategically sampled from five inpatient facilities
and one outpatient opioid maintenance treatment clinic located in two Norwegian
counties. All interviews were transcribed and thereafter analysed with contextual
content analysis aided by the qsr nvivo 8.0 software. This was carried out to obtain
information about the manifest positive and negative content in the interviews. The
results showed that the therapeutic alliance and mutual influences among patients were
important for perceptions of treatment. Frequent staff turnover also related to these
perceptions. The more important domains of recovery were psychosocial functioning
and substance use. The implications of the results were discussed in relation to clinical
practice and further research.
Introduction
Consequences related to substance addiction are highly
complex and do often have severe somatic and psychosocial implications both for the individuals and their significant others. Substance addiction may also have consequences at the broad level of society, for instance in terms
of criminal activities. Because of the diversity of consequences related to substance addiction, treatment consists
of various approaches and models. These approaches
46
Empirical review
Perceptions of treatment and recovery among patients with
substance addiction have received increased attention
2009 Drug and Alcohol Treatment in Central Norway
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T. Nordfjrn et al.
tions between the patients attending the inpatient treatment programmes. Specifically, it was indicated that these
patients had important impacts on each other in terms of
treatment motivation. For example did patients who had
stayed longer in treatment report satisfaction with the
responsibility they had for tutoring new patients enrolled in
the programme. Moreover, the patients were positive when
the facilities planned and offered them aftercare. The most
important categories regarding negative treatment perceptions were related to programme regulations and the
enclosed physical environment at the treatment facilities.
Conners & Franklin (2000) investigated treatment perceptions among female patients enrolled in a programme
for substance addiction treatment in the USA. During focus
groups, patients reported that one of the core benefits of
the programme were that they learnt to cope with life
events without using substances. This was exemplified
through a range of learnt abilities, varying across child
caring, job skills, how to establish a stable economy and
social skills. Patients also pointed to the importance of
specific interventions, such as individual therapy, group
therapy and relapse prevention education. The patients
focused on the therapeutic relationships and told that they
preferred a respecting, understanding and non-confronting
approach from their therapists. These results illustrate that
perceptions of treatment and recovery can not solely be
understood by considering specific interventions and a
limited set of behavioural outcomes. It is likely that
these perceptions are influenced by a complex interaction
between several interrelated components.
Comorbid psychiatric disorders, such as major depression and anxiety, are highly prevalent among patients in
treatment for substance addiction (Landheim et al. 2002).
Furthermore, a substantial number of patients in general
psychiatric health care have substance addiction in addition to other psychiatric diagnoses (Mller & Linaker
2004). Because the majority of these patients share problems, and thus several similar treatment needs, it is possible
that perceptions of treatment and recovery among inpatients in psychiatric health care and substance addiction
treatment have resemblances.
This assumption was supported by an empirical investigation of perceptions among patients in treatment of
depression (Cooper-Patrick et al. 2002). The results indicated that factors such as specific interventions, relations
between the patients and clinical staff, social support
systems and stigma had the strongest influences on perceptions of treatment. These findings are relatively similar to
the results reported in Lovejoy et al. (1995) and Bacchus
et al. (1999). Finney & Moos (1984) underline that variables related to the social climate at the facilities may
influence treatment outcomes. Such variables can for
48
Methods
Sampling procedure
The patients were recruited from five inpatient facilities
and one outpatient OMT facility in two different counties
in the central region of Norway. Two of the inpatient
facilities consist of short-term (8 weeks) treatment programmes mainly aimed at alcohol-related problems. One
of the facilities is a therapeutic community, based on the
2009 Drug and Alcohol Treatment in Central Norway
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T. Nordfjrn et al.
Sample
Of the 14 approached patients, 13 agreed to participate
and the response rate was 92.86%. The age of the patients
ranged from 22 to 47 years (M = 31.38, SD = 8.87). Six
patients were male and seven were female. Five patients
had primary and secondary school as their highest completed education, six patients had completed high school,
and two patients had university or college as their highest
completed education. Six patients were unemployed, four
patients had a full time job, one patient had a part-time job,
and two patients were students.
Regarding substance use, eight patients were polysubstance users, three patients had an addiction pattern
dominated solely by alcohol, whereas two patients had an
opiate-dominated pattern. Six patients had prematurely
dropped out of treatment, and seven patients completed
their programme. Four patients had received treatment in a
short-term inpatient treatment programme, whereas two
patients had attended outpatient OMT. In addition, three
patients had been enrolled in a therapeutic community, and
four patients had attended long-term inpatient treatment.
Among patients who completed treatment, three individuals were currently at the end of their active treatment,
which had on average lasted for 10 months. Four patients
had completed their programme and left the facilities.
Among patients who prematurely dropped out of treatment, two patients attended other inpatient treatment programmes when the interviews were conducted. Treatment
had on average lasted one and a half months for these
patients. Further, two patients who had a premature programme dropout were enrolled in psychiatric outpatient
treatment, which had on average lasted for 2 months.
Semi-structured interviews
The interviews were carried out by two research assistants
affiliated with the project. Both assistants had previous
50
Interview guide
The questions in the interview guide were structured into
three core topics. The first topic was reasons for initiating
treatment. This topic contained questions about how the
patients perceived their psychosocial situation before treatment was initiated, and reasons for why they started in
treatment.
The second topic covered questions related to positive
and negative perceptions of treatment. These were questions about how patients perceived the quality of the
applied interventions, relations to other patients and clinical staff, how their treatment was adjusted to match their
specific problems and how they perceived the regulations in
the treatment programme. This section also covered questions regarding involvement of themselves and significant
others during important decision-making concerning their
treatment.
The third topic included questions about how patients
perceived their current life situation. They were asked
about their current substance use and psychological functioning as compared with before treatment. The patients
were also asked questions about their perceptions concerning their current social support and networks. This section
also covered questions regarding occupational issues, such
as education and employment. After these core topics were
2009 Drug and Alcohol Treatment in Central Norway
Journal compilation 2009 Blackwell Publishing Ltd
Data analysis
When all interviews had been conducted, they were transcribed. The transcribed material consisted of in total
113 056 words. On average each interview included
8697 words. Data were analysed with contextual content
analysis.
Journal compilation
before and after the coded sentence (the context) were first
carefully investigated. When the context was uninformative about positive or negative characteristics, the audiorecordings were consulted, and the intonation of patient
voices was examined to determine whether the content was
positive or negative. Perceptions considered to be neutral
or unrelated to the perceptions under examination were
excluded from further analysis (Weber 1990). When identical sentences were repeated by patients within an interview, these sentences were coded once.
In order to investigate the reliability of coding, the first
author and one independent researcher coded three identical transcribed interviews chosen at random before the first
author coded all interviews. The level of agreement was
recorded and Cohens Kappa (k) was 0.43. According to
Landis & Koch (1977) this could be interpreted as moderate inter-coder reliability. Further, six researchers blind to
the purpose of the study qualitatively investigated the
validity of the definitions used for all categories. Adjustments of the definitions were carried out until sufficient
agreement was obtained.
The specific sentences are presented by free text descriptions. The sentences as expressed by the patients were
articulated into themes in order to cover a more general
meaning and to exclude sensitive data. Such data could for
instance be names of treatment facilities and staff members.
Single sentences that differed to such an extent that they
could not be accumulated in a general thematic description
were located in a description termed other. This was
carried out for space-preserving purposes when these sentences exceeded a threshold of four sentences within a
subcategory.
Results
First, positive and negative perceptions of treatment were
investigated. A general overview of the categories derived
from this analysis is illustrated in Fig. 1. Thereafter,
descriptions of the manifest content of each subcategory
are provided. Tables 1 and 2 illustrate in further detail free
text descriptions of positive and negative sentences in the
subcategories. These tables also provide information about
the frequency of specific content in each category.
Second, positive and negative perceptions of recovery
were examined. A general overview of the identified categories is provided in Fig. 2. Descriptions of the manifest
content in the subcategories were also provided for these
perceptions. Free text descriptions of positive and negative
content related to perceptions of recovery are illustrated in
Tables 3 and 4.
The percentages presented in Figs 1 and 2 illustrate the
proportion of sentences in subcategories in relation to all
51
T. Nordfjrn et al.
53 %
n=254
Relation to
clinical staff
and other
patients
23%
n=108
Therapy and
interventions
18%
n=86
User
involvement
6%
n=29
Aftercare
4%
n=18
Facility
regulations
Treatment
climate
Positive
perceptions
2%
n=8
1%
n=5
47%
n=222
Negative
perceptions
13%
n=61
8%
n=37
7%
n=35
Relation to
clinical staff
and other
patients
Facility
regulations
Therapy and
interventions
6%
n=29
Aftercare
4%
n=20
Treatment
climate
3%
n=15
Facility
resources
3%
n=11
Pacification
2%
n=8
Stigma
1%
n=6
User
involvement
Figure 1
Contextual content analysis of semi-structured interviews (n = 13) positive and negative treatment perceptions
Table 1
Categories regarding positive perceptions in treatment with free text descriptions of statements
Category 1 Relation to clinical staff and other patients 43% (n = 108)
The treatment personnel cared about me and treated me with respect
The relation between the patients was dominated by solidarity
The staff was very available to us
The staff was clever at involving us in social activities
It was possible to talk to the staff about virtually everything
The patients have an indirect therapeutic effect on each other
My therapist had a positive behaviour
When I re-entered treatment after dropping out I felt welcome by the other patients
The other patients helped me to stay abstinent
The staff have confidence, and you are given another chance after a relapse
Other
(n = 254)
36
33
8
5
5
4
3
3
2
2
7
18
11
11
10
8
5
5
4
4
2
8
12
10
6
1
6
3
2
2
5
3
2
1
1
1
Journal compilation
T. Nordfjrn et al.
Table 2
Categories regarding negative perceptions of treatment with free text descriptions of statements
Category 1 Relation to clinical staff and other patients 27% (n = 61)
Patients on methadone maintenance should not be treated together with other patients, because they lack motivation
I failed to establish a good relation to the treatment staff
The overall confidence between patients and clinical staff are not good
The staff are inconsequent and dishonest, because they tell us one thing and thereafter do the opposite
It is not motivating when other patients neglect their working tasks and relapses while in treatment
Specific patients created conflict and were detrimental to the treatment programme overall
I failed to reinitiate treatment because my relationship to the other patients became superficial
I feel that I have abused the confidence that I gained from the other patients
As female you have to be so tough all the time, because it is a male-dominated environment
The staff is to conform when they receive resistance from difficult patients
I felt left alone when the other patients relapsed without involving me
Sometimes the treatment staff puts too much pressure on us in order to involve us in activities
(n = 222)
12
10
9
8
6
6
2
2
2
2
1
1
11
8
8
4
3
2
1
13
9
4
3
2
4
6
6
6
3
8
7
6
3
2
2
4
4
3
2
2
4
3
4
Category 8 Stigma 4% (n = 8)
You are considered as a liar, they only trust you when you can back up your statements by an urine test
We often receive hostile attitudes in the society, and sometimes you encounter treatment personnel with such attitudes
I get provoked when they treat us as monkeys and give us instructions on how to clean the floors
Sometimes the staff consider you as rather unintelligent, but I try to ignore it
4
2
1
1
54
67 %
n=251
Psychosocial
condition
21%
n=78
Substance use
Positive
perceptions
33%
n=124
Substance use
19%
n=71
12%
n=46
7%
n=26
Social network
16%
n=61
6%
n=24
Psychosocial
condition
Occupation
5%
n=18
3%
n=10
Occupation
Housing
4%
n=14
2%
n=6
Economy
Daily routines
2%
n=6
Economy
1%
n=3
Negative
perceptions
Social network
2%
n=6
Housing
2%
n=6
Stigma
Figure 2
Contextual content analysis of semi-structured interviews (n = 13) positive and negative perceptions of recovery
dropped out of their programme. These patients were concerned about inconsequent practice of sanctions after a
relapse to substance abuse. Some patients told that they
had been asked to leave their facilities after a relapse, but
that they had observed other patients who had got off with
a warning for identical violations. Some patients had also
experienced false-positive urine tests because of technical
problems with the applied measurement instruments.
The contextual content analysis identified more negative
than positive perceptions related to aftercare provided by
the treatment facilities. These statements were predominately by patients who prematurely dropped out of treatment. These patients were concerned about the lack of
communication with the treatment facilities and community services after they had left the facilities. Several of these
patients felt that they were left by themselves after treatment and attributed this to increased temptations of substance abuse. Examples of positive perceptions were that
patients had additional outpatients counselling organized
for them after the treatment programme was completed.
Furthermore, some patients told that they had extensive
phone contact with the facilities after they had finalized
their treatment. According to these patients this was helpful
when they were tempted to use substances or experienced
psychosocial difficulties.
Treatment climate was also considered important in
terms of negative treatment perceptions. The content in this
category was mainly about the stability in the working
2009 Drug and Alcohol Treatment in Central Norway
2009 Blackwell Publishing Ltd
Journal compilation
T. Nordfjrn et al.
Table 3
Categories regarding positive perceptions of recovery with free text descriptions of statements
Category 1 Psychosocial condition 31% (n = 78)
I have improved my feelings about myself and I feel more capable of coping with my situation
I am not afraid to speak out my opinions and concerns anymore
My overall psychosocial functioning is better than it was before treatment
Additional help received from psychiatric outpatient clinics improved my psychological functioning
I have become a human being again
My social skills have improved and I feel more comfortable in social situations
I now understand that it is up to me to do something in order to recover
I have had severe psychological problems, but my problems have improved
I am better at setting limits for myself
I have become more open-hearted about my psychiatric disorder
I try to turn negative thoughts into positive thoughts
I am more engaged in having meaningful activities in my everyday life
Previously I did everything to avoid conflicts, but not anymore
I am more patient and tolerating than I was before
There is so much more stability and security in my life now
I am less impulsive than before
Now I feel capable of carrying out interests that I previously had
Other
(n = 251)
17
7
5
4
4
4
3
3
3
3
2
2
2
2
2
2
2
11
8
8
8
6
5
4
4
3
3
3
3
3
3
2
2
2
4
21
10
10
4
2
2
2
2
8
3
3
2
2
2
2
2
1
1
12
1
1
5
1
Category 7 Economy 1% (n = 3)
I have been able to pay my rent because I have taken initiatives for talks with the social office
I have never had any dept
We are currently working with the dept I have obtained during the latest years
1
1
1
56
Table 4
Categories regarding negative perceptions of recovery with free text descriptions of statements
Category 1 Substance use 30% (n = 46)
After dropout I started to use higher doses than before treatment
I have used substances during treatment at this clinic
I lost control when I relapsed, and I have used morphine regularly for one and a half years now
The first thing I did when dropping out was to get hold of a prescription of Vival
Other patients on the clinic have used drugs during their stay and it makes me ambivalent about abstinence
Two months after my dropout I had a series of relapses to alcohol
I just need to have these pills available
In the beginning I solely remembered the positive sides of my abuse, but soon the negative aspects hit back on me
Other
Category 2 Social network 17% (n = 26)
I try to keep my social network away from my problems; I do not want to bother them with my personal problems
The worst issue is to learn what you have been doing to your family
I get sad when I see how my old substance abusing friends are doing
I feel that I have failed my significant others
I am more reflected about my substance abusing friends; it is a social environment based on who has the drugs and not on
real friendship
Other
(n = 24)
7
5
5
5
3
3
3
2
13
4
3
3
2
2
12
4
3
3
2
2
2
8
3
2
2
1
1
1
Category 5 Economy 4% (n = 6)
They should provide more help with financial issues; I have been close to relapse due to a lack of creditors
I had to sell everything I owned in order to finance my substance abuse
I get medicine by my doctor and I have to pay for it myself since the social security barely cover these expenses
3
2
1
Category 6 Housing 4% (n = 6)
I did not have any housing when I left the collective and I lived among substance abusing friends
They have not provided me any help in obtaining an apartment
In order to avoid criminality, I had to sell my house to finance drugs after I relapsed
I think the facility should be more apparent towards social services about housing for substance abusers
2
2
1
1
Category 7 Stigma 4% (n = 6)
I think an important reason of relapse into substance abuse is the attitudes we receive in society
I feel that people judge me as a drug addict
I do not want to tell others that I have been in treatment, I know they will react negatively
4
1
1
Journal compilation
T. Nordfjrn et al.
Relations among patients in treatment were also frequently described (n = 33). Mainly, these statements related
to perceived support from other patients in treatment.
It is noteworthy that several patients reported that other
patients had prevented them from relapses and had motivated them to stay in treatment. This was also reflected by
a patient who told that he had become tempted to neglect
working tasks and instructions, but kept his persistence for
the sake of the other patients. Perceptions in the description
termed other (n = 7) are different statements that occurred
only once in the transcribed material. The majority of
these statements were positive perceptions about treatment
for the male and female patients in the same system. In
addition, some of these perceptions reflected respect for
personnel who regulated and provided feedback on the
behaviours of patients.
As reported in Table 1, several statements (n = 18) indicate successful matching between specific psychosocial
problems and interventions. For instance, patients reported
that they had attended courses that dealt with identification
of automatic processing of negative cognitions in depression. Several of these patients realized that these coping
strategies were relevant to their own problems. Other perceptions (n = 8) consist of positive statements about therapies aimed to improve the relations to significant others, as
well as positive remarks concerning physical training and
relapse prevention courses.
Table 2 shows the breakdown of frequencies and percentages regarding negative perceptions of treatment. The
more important subcategories were relations to clinical
staff and other patients at the facilities (27%), programme regulations (17%) and therapy and interventions
(16%). As reported, negative perceptions regarding the
social climate at the clinics were often discussed in relation to other patients attending the programmes. A relative large proportion (n = 12) of these statements were
specifically targeted to patients who received methadone
or buprenorphine while enrolled into inpatient treatment
together with patients with other addiction patterns.
Several patients reported that they thought individuals
who received methadone or buprenorphine attended
inpatient treatment just to maintain their access to medicaments. They also reported that this negatively influenced the motivation and efforts among other patients.
Underlining the importance of the relation between therapists and patients, barriers for well-functioning therapeutic relationships were often discussed. These barriers
specifically pointed to the importance of consequent information from treatment personnel.
Table 2 reports negative perceptions (n = 37) concerning
facility regulations. As illustrated in the free text descriptions, these statements were mainly about how programme
58
Journal compilation
T. Nordfjrn et al.
Discussion
The core objective of the present study was to investigate positive and negative perceptions of treatment and
recovery among patients with substance addiction. One of
the more interesting findings related to treatment perceptions was the emphasis patients had to aspects of the
social climate at the facilities. A growing body of evidence
(Project MATCH Research Group 1993, Meier et al. 2005)
indicates that the therapeutic alliance explains more variance in treatment outcomes than specific interventions.
The present study supported the notion that a therapeutic
relationship characterized by mutual respect, understanding and availability is of high importance for how patients
perceive the quality of treatment. These results are congruent with previous studies (Lovejoy et al. 1995, Bacchus
et al. 1999) carried out among patients with substance
addiction. Clinical communities tend to consider the therapeutic alliance as an important and robust component for
the quality of treatment. Researchers, however, have only
recently begun to investigate and debate this alliance as
an important ingredient in substance addiction treatment
(Najavits et al. 2000).
The mutual influences among patients in substance
addiction treatment are important to discuss. Data from
the semi-structured interviews indicated that the patients
have mutual influences on each other in terms of treatment motivation. The interviewed patients told that other
patients had convinced them to stay in treatment when they
considered leaving the programmes prematurely. Moreover, some patients told that they refused to re-enter treatment after a premature programme dropout because they
were ashamed and felt they had lost confidence among the
2009 Drug and Alcohol Treatment in Central Norway
Journal compilation 2009 Blackwell Publishing Ltd
Journal compilation
T. Nordfjrn et al.
Acknowledgments
The authors would like to express their gratitude to Katrin
ien and Trine Dyrhaug who carried out the interviews.
Most of all we would like to thank the patients who participated in the study as well as the research coordinators at the
treatment facilities in the Drug and Alcohol Treatment in
Central Norway. The first author is indebted to research
2009 Drug and Alcohol Treatment in Central Norway
2009 Blackwell Publishing Ltd
Journal compilation
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