Addiction

Treatment and recovery as perceived by patients withsubstance addictionjpm_1477 46..64T. 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 . H O L E 3 c a n d . p s y c h o l .1Research 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

Keywords: perception, qualitative

method, recovery, substance addiction,

treatment

Correspondence:

T. Nordfjrn

Drug and Alcohol Competence Center

box 2655

7415 Trondheim

Norway

E-mail: [email protected]

Accepted for publication: 15 June 2009

doi: 10.1111/j.1365-2850.2009.01477.x

Accessible summary

Social relations to therapists and other patients in treatment are important forpositive and negative experiences among patients with substance addiction.

Improvements in mental health and substance use were considered as the moreimportant areas of recovery among these patients.

One of the core reasons for premature dropout could be a failure to establishpositive social relations and temptations to relapse to substance use.

Abstract

Research concerning patients with substance addiction and how they perceive theirtreatment remains scant. The objective of this study was therefore to examine positiveand negative perceptions of treatment and recovery from the perspectives of thesepatients. Data were collected with semi-structured interviews among seven patientswho completed treatment and six patients who prematurely dropped out from theirprogramme (n = 13). Patients were strategically sampled from five inpatient facilitiesand one outpatient opioid maintenance treatment clinic located in two Norwegiancounties. All interviews were transcribed and thereafter analysed with contextualcontent analysis aided by the qsr nvivo 8.0 software. This was carried out to obtaininformation about the manifest positive and negative content in the interviews. Theresults showed that the therapeutic alliance and mutual influences among patients wereimportant for perceptions of treatment. Frequent staff turnover also related to theseperceptions. The more important domains of recovery were psychosocial functioningand substance use. The implications of the results were discussed in relation to clinicalpractice and further research.

Introduction

Consequences related to substance addiction are highlycomplex and do often have severe somatic and psychoso-cial implications both for the individuals and their sig-nificant others. Substance addiction may also have conse-quences at the broad level of society, for instance in termsof criminal activities. Because of the diversity of conse-quences related to substance addiction, treatment consistsof various approaches and models. These approaches

vary considerably in content, durability, intensity andobjectives.

The society has considerable expenses related to sub-stance addiction treatment programmes. Consequently,more studies should be carried out in order to gain knowl-edge about how patients perceive their treatment as wellas recovery. Examples of treatment perceptions are userevaluations about the quality of the applied interventions,availability of treatment staff and programme regula-tions. Because of the variety of biological, psychological

Journal of Psychiatric and Mental Health Nursing, 2010, 17, 4664

46 2009 Drug and Alcohol Treatment in Central NorwayJournal compilation 2009 Blackwell Publishing Ltd

and social consequences related to substance addiction,perceptions of recovery may occur in differentiateddomains ranging across mental health, substance use,employment, economy and social relations.

The last decade, matching between substance addictiontreatment programmes and specific individual needs of thepatients has received increased attention (Smith & Marsh2002). An additional aim has been to increase the involve-ment of the patients and their significant others in decision-making regarding treatment. In order to gain knowledgeabout whether such approaches have succeeded, morestudies should examine how patients perceive treatment.This is an argument underlined by several researchers ingeneral psychiatric health care (Cooper-Patrick et al. 2002)as well as in somatic hospitals (Morgan et al. 2004).Researchers point to patient perceptions as quality indica-tors of the health services delivered. For instance, Finney &Moos (1984) argued that positive perceptions of treatmentare associated with improvements in retention rates andoutcomes among patients with substance addiction. On thecontrary, Joe & Friend (1989) only found a moderate cor-relation between perceptions of treatment and patient out-comes. Despite these contradictions, perceptions among thepatients should be taken into account because it is desirableto carry out treatment that is relevant and well adjusted tothe specific needs of the patients (Jones et al. 1994).

Two of the more important predictors of successfulrecovery are treatment persistence and the duration of timespent in treatment (De Leon et al. 1982). These variablesmay for instance increase the probability of staying absti-nent from substances after leaving the treatment facilities(Gottheil et al. 1992). According to Stark (1992) outcomesamong patients who prematurely drop out of treatment areoften analogous to outcomes among untreated patients.From a scientific and ethical point of view, studies of howpatients perceive treatment and recovery should thereforeinclude patients who prematurely dropped out of theirprogrammes. Investigations of how these patients perceivetreatment and recovery should be prioritized, because suchefforts may identify important risk factors of prematuredropout. After these risk factors have been identified, coun-termeasures can be implemented in clinical practice.

The core aim of the present study was to investigate howpatients with substance addiction perceived their treatmentand recovery. This was carried out among patients fromfive inpatient facilities and one opioid maintenance treat-ment (OMT) clinic in the central region of Norway.

Empirical review

Perceptions of treatment and recovery among patients withsubstance addiction have received increased attention

during the last decades. This has resulted in some studies,which have investigated these psychological entities bothwith qualitative and quantitative approaches. Lovejoyet al. (1995) used a qualitative methodology when patientperceptions of treatment and recovery were investigated ina relapse prevention treatment programme for cocaineaddiction. The results illustrated that one of the moreimportant factors for treatment perceptions was how thepatients evaluated the quality of their relations to treatmentstaff. Specific interventions, for instance group therapy andstrategy courses for coping with abstinence, were also con-sidered as critical components. The most important aspectsrelated to perceptions of recovery were levels of substanceuse, motivational factors as well as the abilities to copewith negative emotions. Interpersonal relations and levelsof self-esteem were also considered important for recovery.

The results from the above-mentioned study indicatedthat the patients were predominately positive to theirtreatment and recovery. As Lovejoy et al. (1995) suggested,however, the results could have been positively biasedbecause all patients recruited to the study had completedtheir treatment programme. The authors thereby suggestedthat samples in qualitative studies should also includepatients who prematurely dropped out of treatment.Furthermore, the sample included significantly moremale patients than female patients. An increasing bodyof empirical evidence suggests that female and malepatients have differential needs in substance addictiontreatment (Copeland & Hall 1992, Nelson-Zlupko et al.1996). Hence studies to come should aim to have a fairlybalanced gender distribution in the samples.

Conners & Franklin (2000) launched an alternativeexplanation for the biased results in studies of perceptionsregarding treatment and recovery. They argued that thesestudies obtain positive results regardless of the investigatedtreatment programmes because of the measurement instru-ments applied in quantitative studies of patient percep-tions. As a possible source of positivity bias they suggestedthat patients do not reflect as freely upon positive andnegative aspects of treatment when the response optionsare restricted to a Likert scale. Although this can notexplain the results in the qualitative study carried out byLovejoy et al. (1995), this argument is still valid whenconsidering the need for more qualitative studies regardingperceptions of treatment and recovery.

Qualitative methods were applied when perceptions ofinpatient treatment were investigated among patients whofinalized treatment at two facilities in the UK (Bacchuset al. 1999). Congruent with Lovejoy et al. (1995), rela-tions to clinical staff were considered as a significant factorin treatment by the interviewed patients. Furthermore, theresults illustrated the importance of the interpersonal rela-

Treatment and recovery as perceived . . .

2009 Drug and Alcohol Treatment in Central NorwayJournal compilation 2009 Blackwell Publishing Ltd

47

tions between the patients attending the inpatient treat-ment programmes. Specifically, it was indicated that thesepatients had important impacts on each other in terms oftreatment motivation. For example did patients who hadstayed longer in treatment report satisfaction with theresponsibility they had for tutoring new patients enrolled inthe programme. Moreover, the patients were positive whenthe facilities planned and offered them aftercare. The mostimportant categories regarding negative treatment percep-tions were related to programme regulations and theenclosed physical environment at the treatment facilities.

Conners & Franklin (2000) investigated treatment per-ceptions among female patients enrolled in a programmefor substance addiction treatment in the USA. During focusgroups, patients reported that one of the core benefits ofthe programme were that they learnt to cope with lifeevents without using substances. This was exemplifiedthrough a range of learnt abilities, varying across childcaring, job skills, how to establish a stable economy andsocial skills. Patients also pointed to the importance ofspecific interventions, such as individual therapy, grouptherapy and relapse prevention education. The patientsfocused on the therapeutic relationships and told that theypreferred a respecting, understanding and non-confrontingapproach from their therapists. These results illustrate thatperceptions of treatment and recovery can not solely beunderstood by considering specific interventions and alimited set of behavioural outcomes. It is likely thatthese perceptions are influenced by a complex interactionbetween several interrelated components.

Comorbid psychiatric disorders, such as major depres-sion and anxiety, are highly prevalent among patients intreatment for substance addiction (Landheim et al. 2002).Furthermore, a substantial number of patients in generalpsychiatric health care have substance addiction in addi-tion to other psychiatric diagnoses (Mller & Linaker2004). Because the majority of these patients share prob-lems, and thus several similar treatment needs, it is possiblethat perceptions of treatment and recovery among inpa-tients in psychiatric health care and substance addictiontreatment have resemblances.

This assumption was supported by an empirical inves-tigation of perceptions among patients in treatment ofdepression (Cooper-Patrick et al. 2002). The results indi-cated that factors such as specific interventions, relationsbetween the patients and clinical staff, social supportsystems and stigma had the strongest influences on percep-tions of treatment. These findings are relatively similar tothe results reported in Lovejoy et al. (1995) and Bacchuset al. (1999). Finney & Moos (1984) underline that vari-ables related to the social climate at the facilities mayinfluence treatment outcomes. Such variables can for

instance be the working environment and social relationsbetween staff and patients. A recent study (Jrgensen et al.2009) found that differences in the social climate measuredby the Ward Atmosphere Scale (Moos 1974) were signifi-cantly related to variations in patient satisfaction among 80patients enrolled in three psychiatric wards in Norway.Indirect support for the importance of the social climate isalso found in validated international questionnaires, whichmeasure perceptions of treatment and recovery amongpatients with substance addiction (e.g. Marsden et al.2000). These questionnaires tend to include test itemsrelated to social climate variables.

In a recent study, interviews about recovery were con-ducted among patients who had attended psychosocialtreatment for alcohol addiction in the UK (Orford et al.2009). Among several interesting findings, the resultsshowed that significant others had important influenceson positive changes regarding substance use and overallmental health. Furthermore, the perceived consequences ofalcohol consumption as well as the determination, commit-ment and decision-making regarding change were con-sidered important. Mcintosh & McKeganey (2000) foundthat patients recovering from substance addiction focusedon several different coping strategies. These strategies werein particular oriented towards avoidance of their formersubstance abusing network and an establishment of mean-ingful occupational activities. The patients also focused atestablishing new social networks that did not abuse sub-stances. These studies indicate that significant others aswell as meaningful occupational activities have importantinfluences on recovery from substance addiction. As apossible explanation, Robins (1993) hypothesized thatoccupational activities and social networks provide socialcontexts that do not facilitate substance use.

Summarizing, the available evidence indicates that thequality of the provided therapies and interventions areimportant for perceptions of treatment. It is also probablethat factors such as social relations among patients, theworking environment at the facilities, communication flowamong staff and patients as well as programme regulationsare important for perceptions of treatment. Unsurprisingly,substance use is an important variable for how patientswith substance addiction perceive their recovery. Severalstudies also point to changes in psychological functioning,abilities to take part in meaningful occupational activitiesand supportive networks as critical components of theseperceptions.

The present study

The majority of the cited studies have solely includedpatients who completed their treatment programme. The

T. Nordfjrn et al.


present study adds to the literature through a qualitativeinvestigation of treatment and recovery among a samplethat includes patients who completed their programme aswell as patients who prematurely dropped out of treat-ment. Further, to the authors knowledge most similarstudies to date have been carried out in the UK and USA.This was also reflected during a search in several interna-tional literature databases, which did not reveal significantadditional studies to those reported in the empirical review.To address some of the gaps indicated in the empiricalreview the specific aims of this study were: (1) to investigatepositive and negative perceptions of substance addictiontreatment; and (2) investigate positive and negative percep-tions of recovery. This was carried out among patients fromfive inpatient clinics and one outpatient OMT clinic in thecentral region of Norway. Patients who completed treat-ment and patients who prematurely dropped out wererecruited from each facility. The patients included in thepresent study were recruited from facilities that differ intreatment approaches and philosophy. Patients who wereenrolled to these facilities also had different psychosocialproblems and addiction patterns. Considering the citedliterature, however, we expected communalities in positiveand negative perceptions of treatment and recovery amongpatients across different treatment programmes.

A qualitative methodology was chosen because of tworeasons. First, qualitative studies often provide a richer anda more complete description of a phenomenon comparedwith quantitative survey investigations. The latter empiri-cal approach is feasible under the right conditions, butusually has a more specific and delimited focus on empiri-cal data (Yardley 2000). Second, there are to the authorsknowledge no validated Norwegian questionnaires thatmeasure treatment perceptions and recovery amongpatients with substance addiction. Although some interna-tional questionnaires concerning perceptions of treatmentand recovery have shown promising feasibility (e.g.Marsden et al. 2000), a review of relevant internationalmeasurement instruments concluded that these question-naires were not suitable in a Norwegian context (Danielsen& Garratt 2007).

Methods

Sampling procedure

The patients were recruited from five inpatient facilitiesand one outpatient OMT facility in two different countiesin the central region of Norway. Two of the inpatientfacilities consist of short-term (8 weeks) treatment pro-grammes mainly aimed at alcohol-related problems. Oneof the facilities is a therapeutic community, based on the

Minnesota model (De Leon 1985). Although there areimportant differences across these programmes, they alsohave similarities. Inpatient treatment is usually targeted tovarious problem domains experienced by poly-substanceusers. Such domains range from psychological and somatichealth, to substance abuse, social relations and regulatoryframework components such as employment, education,economical issues and housing (Bacchus et al. 1999). Inpa-tient treatment usually consists of detoxification followedby psychosocial interventions carried out by multidisci-plinary teams. The patients often receive additionalsupport from various community programmes and after-care services as part of such treatment.

The OMT clinic involved in the study has a programmefor individuals over 25 years of age with an addictionpattern dominated by opiates. An important preconditionfor receiving such treatment is that the individuals havepreviously attended alternative treatment approaches, andthat these approaches have failed at reducing their opiateaddiction. OMT mainly consists of regular psychosocialoutpatient consultations coupled with medically assistedtreatment. In the central region of Norway, this programmeis first carried out at an outpatient facility for 2 years, andpatients are thereafter transferred to community services inan open-ended aftercare system.

During sampling we aimed to recruit a minimum ofone patient who was about to complete treatment inmaximum 2 months and one patient who had prematurelydropped out during the last 6 months from each ofthese treatment facilities. The sample was recruited during18 weeks from June to October 2008. The study wasapproved by the Regional Committee for MedicalResearch Ethics in Central Norway (REK) and the Nor-wegian Social Science Data Services (NSD) before patientswere recruited. Strategic sampling was conducted for thepurpose of recruiting patients who had completed treat-ment and patients who prematurely dropped out fromthe same programmes. An inclusion criteria was that therecruited patients had stayed in treatment long enough toarticulate a perception of the treatment programme (i.e. 3weeks) and that they were 18 years or older. During sam-pling, the distribution of gender, age and education wascarefully monitored by the first author and strategicallybalanced out when necessary.

Research coordinators affiliated with the project pur-posefully selected patients from the patient lists and con-tacted them either by phone or approached them at thefacilities. Thereby the patients were orally informed aboutthe study. The patients also received a consent letter thatdescribed the content of the interviews and underlinedthat participation was voluntary. The consent letter alsoexplained the applied methods to secure confidentiality.



49

The letter was signed by patients who agreed to participateand returned to the research coordinators at the treatmentfacilities.

Among patients who had a premature programmedropout we recruited those who had voluntarily left treat-ment before it was completed as well as patients who hadbeen asked to leave their programmes because of viola-tions of programme regulations. Patients who prematurelydropped out of treatment were complicated to reach, andconsequently we recruited some of these patients from otherinpatient treatment sites than they had previously droppedout from. When these patients had approached a newtreatment programme they were retrospectively interviewedabout the treatment programme relevant to their dropout.

Sample

Of the 14 approached patients, 13 agreed to participateand the response rate was 92.86%. The age of the patientsranged from 22 to 47 years (M = 31.38, SD = 8.87). Sixpatients were male and seven were female. Five patientshad primary and secondary school as their highest com-pleted education, six patients had completed high school,and two patients had university or college as their highestcompleted education. Six patients were unemployed, fourpatients had a full time job, one patient had a part-time job,and two patients were students.

Regarding substance use, eight patients were poly-substance users, three patients had an addiction patterndominated solely by alcohol, whereas two patients had anopiate-dominated pattern. Six patients had prematurelydropped out of treatment, and seven patients completedtheir programme. Four patients had received treatment in ashort-term inpatient treatment programme, whereas twopatients had attended outpatient OMT. In addition, threepatients had been enrolled in a therapeutic community, andfour patients had attended long-term inpatient treatment.

Among patients who completed treatment, three indi-viduals were currently at the end of their active treatment,which had on average lasted for 10 months. Four patientshad completed their programme and left the facilities.Among patients who prematurely dropped out of treat-ment, two patients attended other inpatient treatment pro-grammes when the interviews were conducted. Treatmenthad on average lasted one and a half months for thesepatients. Further, two patients who had a premature pro-gramme dropout were enrolled in psychiatric outpatienttreatment, which had on average lasted for 2 months.

Semi-structured interviews

The interviews were carried out by two research assistantsaffiliated with the project. Both assistants had previous

experiences with semi-structured interviews amongpatients with substance addiction, and they also had rel-evant clinical working experience. An interview guide wasdeveloped in cooperation with the research assistants aswell as experienced clinicians and researchers. To maximizethe reliability and validity of the data, the research assis-tants were extensively trained in the interview guide. Twopilot interviews were carried out before the data collectionwas initiated. The interview guide was adjusted accord-ingly after feedback from these interviews. The researchassistants were supervised to include all questions andtopics in the interview guide during the interviews. Theywere further instructed to use the provided follow-upquestions and to ask for specific examples when patientresponses were considered to provide insufficient informa-tion. It was emphasized that when for instance patientresponses were inflated in a positive direction, the inter-viewer should encourage the patients to also reflect uponnegative aspects regarding the topic of discussion. Finally,the research assistants were encouraged to follow interest-ing cues and topics brought up by the patients. All inter-views were conducted individually in a private room at thetreatment facilities where the patients were recruited. Theinterviews took between 1 and 2 h to complete and wererecorded with a digital sound recorder.

Interview guide

The questions in the interview guide were structured intothree core topics. The first topic was reasons for initiatingtreatment. This topic contained questions about how thepatients perceived their psychosocial situation before treat-ment was initiated, and reasons for why they started intreatment.

The second topic covered questions related to positiveand negative perceptions of treatment. These were ques-tions about how patients perceived the quality of theapplied interventions, relations to other patients and clini-cal staff, how their treatment was adjusted to match theirspecific problems and how they perceived the regulations inthe treatment programme. This section also covered ques-tions regarding involvement of themselves and significantothers during important decision-making concerning theirtreatment.

The third topic included questions about how patientsperceived their current life situation. They were askedabout their current substance use and psychological func-tioning as compared with before treatment. The patientswere also asked questions about their perceptions concern-ing their current social support and networks. This sectionalso covered questions regarding occupational issues, suchas education and employment. After these core topics were

T. Nordfjrn et al.


covered, the patients were asked whether they could reflectupon other topics concerning addiction treatment, whichhad not been discussed during the interviews. The guidealso included a section with questions about demographiccharacteristics, such as age, education, employment statusand time spent in treatment.

Data analysis

When all interviews had been conducted, they were tran-scribed. The transcribed material consisted of in total113 056 words. On average each interview included8697 words. Data were analysed with contextual contentanalysis.

Contextual content analysis

When contextual content analysis is conducted uponwritten material, words, phrases or sentences are usuallyreduced into a smaller number of mutually exclusive catego-ries (Mctavish & Pirro 1990). This method is not limited tocover the frequency of specific words in the material as isthe case with quantitative content analysis (Stemler 2001).One of the critical decisions concerning contextual contentanalysis is the unit of analysis (i.e. the counting unit). In thepresent study, coding was carried out with sentences as thecounting unit. First, all the transcribed interviews were readthrough twice to get a sense of the whole. Second, two maincategories were articulated. These categories were termedtreatment perceptions and perceptions of recovery. Thecoding was carried out by one researcher, and distinctdefinitions of the main categories were established toincrease the likelihood of consistent and valid coding.

Contextual content analysis was conducted with the qsrnvivo 8.0 software. During the coding process each sen-tence belonging to the same concepts was given a commonlabel. The sentences were categorized according to whetherthey were positive or negative in content. Subcategories withbelonging definitions were inductively established through-out the coding process. A positive and negative distinctionwas made because of two reasons. First, this allowed us toillustrate and examine contradictory evidence in the mate-rial more directly. In addition, preliminary reading showedthat most sentences regarding perceptions of treatment andrecovery were either positive or negative in content.

During coding the context of sentences was carefullyattended to. This means that a typical negative event, suchas for instance a relapse to substance use, could be definedas a positive event if the patients mentioned such events ina positive context (e.g. learning useful coping strategies bythe relapse). When the coder encountered items that werecomplicated to label either positive or negative, sentences

before and after the coded sentence (the context) were firstcarefully investigated. When the context was uninforma-tive about positive or negative characteristics, the audio-recordings were consulted, and the intonation of patientvoices was examined to determine whether the content waspositive or negative. Perceptions considered to be neutralor unrelated to the perceptions under examination wereexcluded from further analysis (Weber 1990). When iden-tical sentences were repeated by patients within an inter-view, these sentences were coded once.

In order to investigate the reliability of coding, the firstauthor and one independent researcher coded three identi-cal transcribed interviews chosen at random before the firstauthor coded all interviews. The level of agreement wasrecorded and Cohens Kappa (k) was 0.43. According toLandis & Koch (1977) this could be interpreted as moder-ate inter-coder reliability. Further, six researchers blind tothe purpose of the study qualitatively investigated thevalidity of the definitions used for all categories. Adjust-ments of the definitions were carried out until sufficientagreement was obtained.

The specific sentences are presented by free text descrip-tions. The sentences as expressed by the patients werearticulated into themes in order to cover a more generalmeaning and to exclude sensitive data. Such data could forinstance be names of treatment facilities and staff members.Single sentences that differed to such an extent that theycould not be accumulated in a general thematic descriptionwere located in a description termed other. This wascarried out for space-preserving purposes when these sen-tences exceeded a threshold of four sentences within asubcategory.

Results

First, positive and negative perceptions of treatment wereinvestigated. A general overview of the categories derivedfrom this analysis is illustrated in Fig. 1. Thereafter,descriptions of the manifest content of each subcategoryare provided. Tables 1 and 2 illustrate in further detail freetext descriptions of positive and negative sentences in thesubcategories. These tables also provide information aboutthe frequency of specific content in each category.

Second, positive and negative perceptions of recoverywere examined. A general overview of the identified cat-egories is provided in Fig. 2. Descriptions of the manifestcontent in the subcategories were also provided for theseperceptions. Free text descriptions of positive and negativecontent related to perceptions of recovery are illustrated inTables 3 and 4.

The percentages presented in Figs 1 and 2 illustrate theproportion of sentences in subcategories in relation to all



51

sentences coded into the two major categories respectively.Percentages in the tables show in further detail the propor-tions of sentences in subcategories, according to whetherthey were positive or negative in content, within these twomajor categories.

Positive and negative perceptions of treatment

Contextual content analysis was conducted to investigatepositive and negative perceptions of treatment. Figure 1illustrates the outcome of this analysis. A total numberof 476 sentences were identified. The results showed thatboth positive (53%) and negative (47%) perceptions werecommon among the patients.

Six categories concerning positive treatment percep-tions were identified: (1) relation to clinical staff and otherpatients; (2) therapy and interventions; (3) user involve-ment; (4) aftercare; (5) facility regulations; and (6) treat-ment climate. Negative content revealed the same sixcategories in addition to: (7) pacification; (8) stigma; and(9) facility resources. The most frequent positive percep-tions concerned relations to clinical staff and other patientsat the treatment facilities. Specific therapies and interven-tions were also considered as important contributors to

positive treatment perceptions among the interviewedpatients. In terms of negative perceptions of treatment,relations to staff and other patients was the most importantcategory.

As illustrated in Fig. 1, relations to clinical staff andother patients was the most important category in terms ofpositive as well as negative perceptions of treatment. Thepatients discussed how other patients repeatedly had con-vinced them to stay at the clinics, when they were temptedto relapse to substances or leave prematurely. The patientsalso indicated that they appreciated treatment togetherwith other individuals in similar situations. These patientsreported that other patients understood their problems andconcerns better than family and friends outside the clinics.In relation to negative perceptions of treatment, it wasunderlined that arguments occurred relatively often amongpatients in treatment. These patients also told that otherpatients had tried to sabotage the treatment programme forthem. In relation to this, negative perceptions of beingtreated together with patients who lacked sufficient moti-vation were frequently discussed.

Perceptions of therapy and interventions were mainlypositive among the interviewed patients. Several expres-sions showed that the patients experienced group therapy

Treatment perceptions (n=476)

Relation to clinical staff and other patients

Therapy and interventions

User involvement

Facility regulations

Treatment climate

Facility resources

Positive perceptions

Negative perceptions

53 % n=254

47% n=222

23% n=108

18% n=86

6% n=29

2% n=8

1% n=5

Relation to clinical staff and other patients

Therapy and interventions

User involvement

Facility regulations

Treatment climate

Pacification

Stigma

13% n=61

8% n=37

7% n=35

4% n=20

3% n=15

3% n=11

2% n=8

1% n=6

Aftercare 4% n=18

Aftercare 6% n=29

Figure 1Contextual content analysis of semi-structured interviews (n = 13) positive and negative treatment perceptions

T. Nordfjrn et al.


as a setting where they were given the opportunity todiscuss their problems and needs with others. Severalpatients also pointed to positive effects from learning prac-tical abilities, such as cleaning and cooking. Excursions innature were evaluated as a positive shift of scene, where thepatients could focus on other stimuli than intoxication.Some patients discussed negative perceptions related to atoo low frequency of conversational therapy. In addition,several female patients pointed to the lack of dedicatedtherapy groups for male and female patients.

Perceptions regarding active user involvement in treat-ment were mainly positive in content. Positive perceptionswere discussed in relation to individual treatment plansarticulated together with clinical staff. The patients also

appreciated that significant others were invited to thefacilities for conversations, because these conversationsprovided their social networks with information abouttheir situation and treatment progress. Negative percep-tions regarding user involvement were mainly expressed bypatients in OMT. These patients raised concern about thelack of influence they had on their doses during methadoneor buprenorphine escalation. These patients reported thatthey had repeatedly asked to reduce their methadone dosesbecause of severe negative side effects, but these requestswere not accommodated by the clinic.

Figure 1 shows that facility regulations were mainlyconsidered in negative terms. These considerations weremore often articulated by patients who had prematurely

Table 1Categories regarding positive perceptions in treatment with free text descriptions of statements

Category 1 Relation to clinical staff and other patients 43% (n = 108) (n = 254)The treatment personnel cared about me and treated me with respect 36The relation between the patients was dominated by solidarity 33The staff was very available to us 8The staff was clever at involving us in social activities 5It was possible to talk to the staff about virtually everything 5The patients have an indirect therapeutic effect on each other 4My therapist had a positive behaviour 3When I re-entered treatment after dropping out I felt welcome by the other patients 3The other patients helped me to stay abstinent 2The staff have confidence, and you are given another chance after a relapse 2Other 7

Category 2 Therapy and interventions 34% (n = 86)The interventions were well adjusted to my psychosocial problems 18Group therapy made me talk about problems related to economy, social networks and addiction 11Excursions in nature were especially meaningful 11Therapy learnt me strategies for coping with my substance addiction 10Group therapy allows us to criticize, praise and draw boundaries for each other 8In therapy I learnt to structure and handle practical activities 5Methadone improved our overall health and removed our abstinences 5I learned a lot from group therapy, because I could discuss my problems with people who shared the same problems 4Conversation groups helped me in focusing deeply on myself 4Group therapy helped, because it made me more illustrious 2Other 8

Category 3 User involvement 11% (n = 29)I took part in decisions regarding my treatment and activities, and we wrote guidelines for my treatment together 12They ask and listen to my opinions regarding the problem domains we should pay attention to 10My significant others were invited to conversations and gained insight into my situation 6I think we have been successful in changing parts of the treatment structure at this facility 1

Category 4 Aftercare 7% (n = 18)It is comforting to know that I can always call the facility when I have had relapses or other problems in my daily life 6They have made it so I get regular psychiatric consultations and help at the social office after my stay 3I receive great aftercare from social services in the municipality 2The staff even invited me over to dinner and they have visited me at home 2Other 5

Category 5 Facility regulations 3% (n = 8)After a while I adapted to the regulations at the facility 3In retrospect I think most of the regulations at the facility make sense 2I did not have any problems regarding the facility regulations 1I understand that we have to take urine tests to prove that we are clean 1One cannot suddenly change the regulations, because then treatment would not be the same for all individuals 1

Category 6 Treatment climate 2% (n = 5)I was in a safe and stable environment where it was possible to focus on other things than intoxication 5



53

Table 2Categories regarding negative perceptions of treatment with free text descriptions of statements

Category 1 Relation to clinical staff and other patients 27% (n = 61) (n = 222)Patients on methadone maintenance should not be treated together with other patients, because they lack motivation 12I failed to establish a good relation to the treatment staff 10The overall confidence between patients and clinical staff are not good 9The staff are inconsequent and dishonest, because they tell us one thing and thereafter do the opposite 8It is not motivating when other patients neglect their working tasks and relapses while in treatment 6Specific patients created conflict and were detrimental to the treatment programme overall 6I failed to reinitiate treatment because my relationship to the other patients became superficial 2I feel that I have abused the confidence that I gained from the other patients 2As female you have to be so tough all the time, because it is a male-dominated environment 2The staff is to conform when they receive resistance from difficult patients 2I felt left alone when the other patients relapsed without involving me 1Sometimes the treatment staff puts too much pressure on us in order to involve us in activities 1

Category 2 Facility regulations 17% (n = 37)Several of the regulations result in a loss of personal independence 11The sanctions administered after a relapse are inconsequent and too often unreasonable 8Because this facility does not accept Vival use, my anxiety increased to such levels that I was unable to stay 8Structuring and planning of everyday activities was extremely difficult and unfamiliar 4The equipment and routines for urine tests too often result in false-positive results 3To me it seems unreasonable that we are not allowed to use protein shake to improve our physique 2I do not understand why they simply throw patients who fail to comply with the regulations out of the programme without

offering alternative treatment facilities for those patients1

Category 3 Therapy and interventions 16% (n = 35)Therapy focused too much on addiction, and psychological problems were not discussed 13Group therapy focused too much on collective problems while they should have paid more attention to the individuals 9I grew tired of therapy, because I had to scrutinize and tell about my personal life all the time 4The frequency of individual conversation therapy was too low 3I think the treatment programme was too tough in the beginning and the patients got exhausted 2Other 4

Category 4 Aftercare 13% (n = 29)After my dropout I heard nothing more from the treatment facility 6I was looking forward to be transferred to community services, but there is something lacking in what they can offer 6I think they should have something to offer us when we drop out of treatment prematurely 6They should provide an emergency service that we can attend when we feel that a relapse is tempting 3Other 8

Category 5 Treatment climate 9% (n = 20)The qualities of communication and the management structure at the facility are dysfunctional for us 7It is difficult to establish trust and continuity because there are replacements among the clinical staff all the time 6Several persons among the clinical staff seemed unmotivated and stressed at work 3The communication flow between the clinical staff was poor 2The staff ,who were present during evenings and nights, did not have sufficient competence and they were too few 2

Category 6 Facility resources 7% (n = 15)The treatment unit has enrolled too many patients compared to their available personnel 4Due to an insufficient number of qualified personnel, patients do not get their required amount of counselling 4The treatment unit can not offer us regular physical training due to the lack of personnel 3All of a sudden our motivational activity funds were removed, such actions generate uncertainty 2We get jealous when we hear about patients from other clinics who travel abroad 2

Category 7 Pacification 5% (n = 11)Sometimes I get a feeling that the only reason we are around is to deliver negative urine tests 4It is meaningful to become abstinent, but the things we do at the clinic do not provide meaning to our lives 3Other 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 4We often receive hostile attitudes in the society, and sometimes you encounter treatment personnel with such attitudes 2I get provoked when they treat us as monkeys and give us instructions on how to clean the floors 1Sometimes the staff consider you as rather unintelligent, but I try to ignore it 1

Category 9 User involvement 3% (n = 6)The staff carries out the actions they believe is correct and do not listen to our opinions and needs at all 6

T. Nordfjrn et al.


dropped out of their programme. These patients were con-cerned about inconsequent practice of sanctions after arelapse to substance abuse. Some patients told that theyhad been asked to leave their facilities after a relapse, butthat they had observed other patients who had got off witha warning for identical violations. Some patients had alsoexperienced false-positive urine tests because of technicalproblems with the applied measurement instruments.

The contextual content analysis identified more negativethan positive perceptions related to aftercare provided bythe treatment facilities. These statements were predomi-nately by patients who prematurely dropped out of treat-ment. These patients were concerned about the lack ofcommunication with the treatment facilities and commu-nity services after they had left the facilities. Several of thesepatients felt that they were left by themselves after treat-ment and attributed this to increased temptations of sub-stance abuse. Examples of positive perceptions were thatpatients had additional outpatients counselling organizedfor them after the treatment programme was completed.Furthermore, some patients told that they had extensivephone contact with the facilities after they had finalizedtheir treatment. According to these patients this was helpfulwhen they were tempted to use substances or experiencedpsychosocial difficulties.

Treatment climate was also considered important interms of negative treatment perceptions. The content in thiscategory was mainly about the stability in the working

environments at the facilities. Patients frequently reportedhow continuous replacements among the clinical staffmade them feel insecure and unable to establish adequatetherapeutic relationships over time. For example, somepatients told that they spent more time by presenting theirproblems to new employees than learning coping strategiesfor these problems. The patients also pointed to communi-cation problems between clinical staff and facility manage-ment as an obstacle of efficient treatment.

Figure 1 reports that perceptions related to the availableresources at the facilities were important for negative per-ceptions of treatment. These statements were mainly aboutfinancial resources available to the patients and an insuffi-cient number of personnel at the facilities. Patients toldthat they received insufficient frequencies of conversationaltherapy and physical activity because of the lack of quali-fied personnel. Related to this, patients questioned thenumber of people who were available to them during eve-nings and nights as well as the clinical competence amongstaff on night-shifts. In addition, patients talked abouteconomical incentives and recreational funds that had beendivested from them because the facilities had been told tospend less economical resources.

Another important aspect of negative treatment percep-tions concerned pacification and boredom during treat-ment. Some patients told that they had frequently been leftalone, because the clinical staff had meetings. Patients alsotold that they were in lack of meaningful activities at the

Perceptions of recovery (n=375)

Substance use

Social network

Stigma

Psychosocial condition

Occupation

Positive perceptions

Negative perceptions

67 % n=251

33% n=124

21% n=78

19% n=71

16% n=61

5% n=18

Psychosocial condition

Substance use

Social network

Occupation

Economy

Housing

12% n=46

7% n=26

6% n=24

3% n=10

2% n=6

2% n=6

2% n=6

Housing

Daily routines

Economy

4% n=14

2% n=6

1% n=3

Figure 2Contextual content analysis of semi-structured interviews (n = 13) positive and negative perceptions of recovery



55

Table 3Categories regarding positive perceptions of recovery with free text descriptions of statements

Category 1 Psychosocial condition 31% (n = 78) (n = 251)I have improved my feelings about myself and I feel more capable of coping with my situationI am not afraid to speak out my opinions and concerns anymore 17My overall psychosocial functioning is better than it was before treatment 7Additional help received from psychiatric outpatient clinics improved my psychological functioning 5I have become a human being again 4My social skills have improved and I feel more comfortable in social situations 4I now understand that it is up to me to do something in order to recover 4I have had severe psychological problems, but my problems have improved 3I am better at setting limits for myself 3I have become more open-hearted about my psychiatric disorder 3I try to turn negative thoughts into positive thoughts 3I am more engaged in having meaningful activities in my everyday life 2Previously I did everything to avoid conflicts, but not anymore 2I am more patient and tolerating than I was before 2There is so much more stability and security in my life now 2I am less impulsive than before 2Now I feel capable of carrying out interests that I previously had 2Other 2

Category 2 Substance use 28% (n = 71) 11My control over my substance use has improved and I am confident that I can become totally abstinent one day 8When I have a relapse, I have more control and succeed in reducing substance consumption faster than before 8I do not use substances anymore, I am clean 8Certain situations may trigger temptation to use substances, but I have learnt how to cope with those situations 6I have learnt to value a life without substances 5I have gained perspective about the social destructiveness of my substance abuse 4Treatment has significantly increased the threshold for using substances 4During the first period before my relapse, the medicine worked and I had no abstinences and used no drugs 3Obviously relapses are negative, but I now have a bad conscience after each of them and feel that I am learning 3I have started to focus on my interests instead of intoxication 3Now I am able to walk downtown and turn down offers of drugs 3Previously I used Vival for breakfast, but now I have significantly reduced my use of pills 3After treatment I have been much more open-hearted with my alcohol problems 3I feel proud about that I have not relapsed 2I know that I cannot enjoy alcohol in a normal manner and have to avoid drinking 2I have become more aware about why I used substances 2Other 4

Category 3 Social network 24% (n = 61)The relation to my family and significant others has improved significantly 21My loved one supports me in remaining abstinent 10My family supported and motivated me throughout treatment 10I do not have any contact with those people I used to do drugs with, because I want to stay clean 4The relation to my significant others have always been good 2I got several new friends now 2I have a good social network, who do not use substances 2I am more reflected about my substance abusing friends; it is a social environment based on who has the drugs and not on real friendship 2Other 8

Category 4 Occupation 7% (n = 18)I started my own business when I was in treatment 3

I am much more motivated to work now than I was before treatment 3I started to work with horses and begun at school again 2During this summer I have worked for my parents and I will soon start to study again 2I have been successful in obtaining a new job 2I have ambitions of getting a job soon 2Now I write applications and I am really looking forward to start working 2This has been a good period for me and I have got a lot of work done 1I still have my old job 1

Category 5 Housing 6% (n = 14)I have obtained a new apartment with good help from the facility 12I have always had a place to live 1You soon understand the importance of having your own place, I do not want to live at random places 1

Category 6 Daily routines 2% (n = 6)I have learnt practical skills, such as cleaning, which I use regularly in my every day life now 5Although I do not have anything to do a particular day, I understand that I should get out of bed and eat breakfast 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 1I have never had any dept 1We are currently working with the dept I have obtained during the latest years 1

T. Nordfjrn et al.


facilities, and consequently felt bored and passive. Finally,a few negative statements were about stigmatization at thetreatment sites. These statements were mainly related to alack of confidence in patients abilities to tell the truth andto carry out simple instructions.

The specific breakdown of frequencies and percentagesregarding positive treatment perceptions is reported inTable 1. As illustrated, social relations at the facilities(43%) and therapy and interventions (34%) were the twomost important subcategories regarding positive treat-ment perceptions. As reported in the free text descrip-tions, positive content regarding social relations at the

facilities were often related to levels of respect and carereceived from treatment personnel (n = 36). These per-ceptions were mainly about qualities in the therapeuticrelationships between treatment personnel and thepatients. A common statement pointed to the capabilitiesof therapists to establish contact and show genuine inter-est in the unique situations of the patients. Several ofthese statements were also about therapists who providedpositive feedback to the patients when they made progres-sion in treatment. The results show that when suchfactors were present, they were highly appreciated by thepatients.

Table 4Categories regarding negative perceptions of recovery with free text descriptions of statements

Category 1 Substance use 30% (n = 46) (n = 24)After dropout I started to use higher doses than before treatment 7I have used substances during treatment at this clinic 5I lost control when I relapsed, and I have used morphine regularly for one and a half years now 5The first thing I did when dropping out was to get hold of a prescription of Vival 5Other patients on the clinic have used drugs during their stay and it makes me ambivalent about abstinence 3Two months after my dropout I had a series of relapses to alcohol 3I just need to have these pills available 3In the beginning I solely remembered the positive sides of my abuse, but soon the negative aspects hit back on me 2Other 13

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 4The worst issue is to learn what you have been doing to your family 3I get sad when I see how my old substance abusing friends are doing 3I feel that I have failed my significant others 2I am more reflected about my substance abusing friends; it is a social environment based on who has the drugs and not onreal friendship

2

Other 12

Category 3 Psychosocial condition 16% (n = 24)I have been diagnosed with schizophrenia and I am struggling both with the symptoms and social implications 4I feel more miserable than ever before 3Many of the psychological problems are still present 3I feel that I have failed 2My self-confidence is far from good 2I feel indifferent about being alive or dead 2Other 8

Category 4 Occupation 7% (n = 10)I lost my job in the process 3I have not begun any studies or job yet 2My job situation is unchanged; I have no job 2I was unable to keep studying 1I am under a contract with my workplace and they will take random urine tests and may come over to my house 1I still have a job, but I have to stay on sick leave for a long time 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 3I had to sell everything I owned in order to finance my substance abuse 2I get medicine by my doctor and I have to pay for it myself since the social security barely cover these expenses 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 2They have not provided me any help in obtaining an apartment 2In order to avoid criminality, I had to sell my house to finance drugs after I relapsed 1I think the facility should be more apparent towards social services about housing for substance abusers 1

Category 7 Stigma 4% (n = 6)I think an important reason of relapse into substance abuse is the attitudes we receive in society 4I feel that people judge me as a drug addict 1I do not want to tell others that I have been in treatment, I know they will react negatively 1



57

Relations among patients in treatment were also fre-quently described (n = 33). Mainly, these statements relatedto perceived support from other patients in treatment.It is noteworthy that several patients reported that otherpatients had prevented them from relapses and had moti-vated them to stay in treatment. This was also reflected bya patient who told that he had become tempted to neglectworking tasks and instructions, but kept his persistence forthe sake of the other patients. Perceptions in the descriptiontermed other (n = 7) are different statements that occurredonly once in the transcribed material. The majority ofthese statements were positive perceptions about treatmentfor the male and female patients in the same system. Inaddition, some of these perceptions reflected respect forpersonnel who regulated and provided feedback on thebehaviours of patients.

As reported in Table 1, several statements (n = 18) indi-cate successful matching between specific psychosocialproblems and interventions. For instance, patients reportedthat they had attended courses that dealt with identificationof automatic processing of negative cognitions in depres-sion. Several of these patients realized that these copingstrategies were relevant to their own problems. Other per-ceptions (n = 8) consist of positive statements about thera-pies aimed to improve the relations to significant others, aswell as positive remarks concerning physical training andrelapse prevention courses.

Table 2 shows the breakdown of frequencies and per-centages regarding negative perceptions of treatment. Themore important subcategories were relations to clinicalstaff and other patients at the facilities (27%), pro-gramme regulations (17%) and therapy and interventions(16%). As reported, negative perceptions regarding thesocial climate at the clinics were often discussed in rela-tion to other patients attending the programmes. A rela-tive large proportion (n = 12) of these statements werespecifically targeted to patients who received methadoneor buprenorphine while enrolled into inpatient treatmenttogether with patients with other addiction patterns.Several patients reported that they thought individualswho received methadone or buprenorphine attendedinpatient treatment just to maintain their access to medi-caments. They also reported that this negatively influ-enced the motivation and efforts among other patients.Underlining the importance of the relation between thera-pists and patients, barriers for well-functioning therapeu-tic relationships were often discussed. These barriersspecifically pointed to the importance of consequent infor-mation from treatment personnel.

Table 2 reports negative perceptions (n = 37) concerningfacility regulations. As illustrated in the free text descrip-tions, these statements were mainly about how programme

regulations influenced the perceptions of personal freedomamong the patients. Several patients reported that they hadlost their autonomy because of mandatory socialization andmonitoring of their behaviour, especially during early phasesof their programme. Furthermore, it was reported that theregulations were practised inconsequently, and that patientsreceived different sanctions after identical violations of pro-gramme regulations. The results indicate that the patientswere more concerned about how the regulations werecarried out in practice, rather than negative towards theregulative nature of the treatment programmes.

Negative treatment perceptions were also discussed inrelation to the therapies and interventions conducted at thefacilities. The most frequent statements (n = 13) postulatedthat the interventions were too focused on substance addic-tion instead of underlying psychological problems. Severalpatients, who had been diagnosed with depression andanxiety, reported that they were frustrated when therapygroups merely discussed strategies for coping with alcoholabstinence. According to them, this was done without dis-cussing the underlying causes of alcohol consumption,which were attributed to psychological disorders (i.e. self-medication) by these patients. Miscellaneous statements(n = 4) indicated a lack of dedicated therapy groups forfemale patients and specialized therapies for patients whoused antipsychotic medication.

Positive and negative perceptions of recovery

The next step was to investigate the content of positive andnegative perceptions regarding recovery. The outcome ofthis analysis is illustrated in Fig. 2. As reported a totalnumber of 375 statements were identified. Of these sen-tences, the majority (67%) was positive whereas 33% werenegative. Seven categories emerged for positive perceptionsof recovery: (1) psychosocial condition; (2) substance use;(3) social network; (4) occupation; (5) housing; (6) dailyroutines and (7) economy. Although negative perceptionsrevealed similar categories, a category termed (8) stigmaemerged for these perceptions and the category nameddaily routines was not revealed. The results indicated thatthe most important positive perceptions of recovery wererelated to the psychosocial situation among patients. Per-ceptions of recovery related to substance use and socialnetworks were also important. Negative perceptions weremainly related to substance use.

Positive perceptions of recovery were frequentlyreported in relation to the psychosocial conditions amongpatients. These perceptions were mainly about psychiatricsymptoms and general psychological functioning. Forinstance, several patients reported that their capabilities ofcontrolling their impulsive behaviours had improved.

T. Nordfjrn et al.


Negative perceptions were mainly related to psychiatricsymptoms. Patients reported that they experienced symp-toms related to depression and anxiety after treatment.

As reported in Fig. 2, the patients had both positive andnegative perceptions of recovery regarding substance use.Several patients reported that they had started to focus ontheir hobbies and interests instead of intoxication. Anumber of patients also told that they were totally absti-nent from substances after treatment. Examples of negativeaspects of recovery were that some patients reported higherlevels of substance use immediately after treatment termi-nation. This was more common among patients who had apremature dropout from their programme.

The majority of statements concerning changes in socialnetworks were positive in content. Patients reported thatthey were motivated to establish new social relations andtold that they did not want to return to the substanceabusing networks they were part of before treatment. Itwas also reported that they had learnt how to talk abouttheir addiction with their children. Several patients alsohad established contact with old friends, who they hadexcluded when they initiated their substance abuse. On thenegative side, patients told that they often experienced abad conscience because they had discovered how destruc-tive their behaviours had been to their significant others.

Recovery related to occupational activities, such asemployment and education, was fairly balanced betweenpositive and negative perceptions (Fig. 2). Although severalpatients reported that they had neglected their occupa-tional activities because of substance addiction, they alsotold that they currently felt more motivated to reinitiatesuch activities. Some patients reported that they had beencapable of keeping their jobs throughout the treatmentprogramme and were looking forward to return to theiroccupational activities.

As shown in Fig. 2, several patients mentioned thathousing was an important aspect of recovery. Most of thesestatements were positive in content. A number of patientstold that that they had obtained a new apartment in col-laboration with the treatment facilities, and that this pro-vided them with a safe framework that helped them instaying abstinent from substances. Some patients also told,however, that they had failed to obtain housing and wereconsequently concerned that they had to return to neigh-bourhoods with extensive substance abuse in order to havea place to live after treatment.

The manifest content of the category termed daily rou-tines covers perceptions by patients who told that theytransferred some of the routines they learnt at the facilitiesover to their daily lives. It was for instance stated thatpatients had learnt how to keep a regular circadian rhythmand learnt practical abilities, such as cooking and cleaning,

during their stay at the facilities. These patients reportedthat they currently applied these abilities actively in theirdaily lives. Related to life outside the clinics, economy wasalso regarded as an important issue for recovery by somepatients. One patient told that he currently was workingwith financial creditors, and that the facility helped him todeal with his personal Department. On the negative side,one patient mentioned that the facility had not aided him interms of financial issues, and that he almost relapsed tosubstances because of the Department he had established.Furthermore, a few of the interviewed patients pointed tostigma as a negative factor in recovery. These patientsthought that they were negatively evaluated as ex-addictsby other people in society. Some of these individuals alsotold that they hesitated to tell friends and colleagues thatthey had been in treatment in fear of the social reactions.

Table 3 illustrates in further detail the breakdown offrequencies and percentages concerning subcategories ofpositive perceptions about recovery. As illustrated, themore important subcategories were psychosocial condi-tions (31%), substance use (28%) and social network(24%). As reported in the free text descriptions of state-ments, the most dominant improvements concerningpsychosocial conditions were related to self-confidence andsocial abilities. Patients reported that they had regainedtheir beliefs in their personal coping skills and told thattheir threshold to openly express their opinions and con-cerns to others were markedly reduced. Such improvementswere by some patients attributed to additional psychiatricservices received in outpatient programmes. The descrip-tion with other statements (n = 11) contains perceptionsabout improved conscience as well as increased abilities toengage in daily duties.

Concerning recovery in substance use, the patients oftentold that they had improved their control and gained copingstrategies regarding abstinence. Several patients told thatthey had improved their abilities to identify situations wherethey were likely to use substances, and that they were morecapable of coping with these situations without relapsing tosubstance abuse after treatment. Although, several patientstold that they were totally abstinent from substances aftertreatment, this was more frequent among patients whocompleted their programme. Patients who prematurelydropped out of treatment had more often positive percep-tions regarding relapse. Some of these perceptions wereconsidered as positive in content, because the context ofthese sentences indicated that the relapses lasted for ashorter period than before treatment. Some of these sen-tences also indicated that the patients had increased theircontrol when relapses occurred. Other perceptions (n = 4)were sentences from patients who had used substances aftertreatment, but realized that substance abuse did not add



59

anything to their quality of life. This description alsocontains statements from patients who avoided substancesafter treatment, because they had learnt that substancescould trigger symptoms related to psychiatric disorders.

Perceptions of improvements in relations to significantothers dominated the category concerning social networks(n = 21). Specifically, patients reported improved capabili-ties of communicating their addiction-related problems totheir significant others. Several patients told that this con-tributed to an improved understanding and support fromtheir family members and friends. It was also reported thatpatients who were involved in intimate relationships gainedfurther motivation for recovery throughout and after thetreatment programme. Some patients indicated that animportant strategy in order to avoid relapses was to avoidtheir previously substance abusing networks. It was indi-cated that these patients aimed to establish new socialnetworks through occupational activities, such as work oreducation. Other statements (n = 8) were mainly aboutabilities to socialize with friends and colleagues who usedalcohol, without becoming tempted to relapse.

Table 4 shows that substance use (30%), social network(17%) and psychosocial conditions (16%) were the mostimportant subcategories related to negative perceptions ofrecovery. The patients often described negative perceptionsof recovery related to relapse to substance abuse. Thesestatements were more common among patients who pre-maturely dropped out of their programme. Several patientsreported that they had used higher doses of substancesimmediately after programme dropout compared withbefore treatment was initiated. Most of these patientsattributed increased substance use to perceptions of failure,as well as a lack of meaningful occupational activities whenthey had left the facilities. Other statements (n = 13) indi-cated temptations to relapse to substance abuse after sig-nificant negative life events. Examples were brokenintimate relationship, refusals of job applications anddecease among close friends.

The more frequent (n = 4) statements about social net-works were stated by patients who told that they wouldreceive help from significant others if they asked, butreported that they did not want to involve them in theirpersonal problems. The patients also told that one of themost disturbing aspects of recovery from substance addic-tion was to learn that their activities had been destructiveupon their significant others. Miscellaneous statements(n = 12) related to negative perceptions were reported bypatients who returned to their substance abusing networksafter treatment. These perceptions were mainly about howthese networks made them ambivalent in terms of stayingabstinent from substances. In addition, this descriptioncovers statements regarding inabilities to focus on personal

recovery because of conflicts with significant others outsidethe facilities.

In terms of the psychosocial conditions among patients,negative statements were predominately related to symp-toms of psychological disorders. Table 4 illustrates thatpatients reported that they experienced severe symptomsrelated to psychological disorders ranging from schizophre-nia to depression and anxiety. Several of these patientsreported that they had been diagnosed with comorbidpsychological disorders during treatment. Although themajority of these statements were articulated by patientswho prematurely dropped out of their programme, somepatients who completed treatment told that they frequentlyexperienced symptoms related to these psychological dis-orders. Other statements (n = 8) concerned perceptionsregarding a reduced belief in psychological improvement aswell as perceptions of shame and guilt related to prematureprogramme dropout.

Discussion

The core objective of the present study was to investi-gate positive and negative perceptions of treatment andrecovery among patients with substance addiction. One ofthe more interesting findings related to treatment per-ceptions was the emphasis patients had to aspects of thesocial 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 vari-ance in treatment outcomes than specific interventions.The present study supported the notion that a therapeuticrelationship characterized by mutual respect, understand-ing and availability is of high importance for how patientsperceive the quality of treatment. These results are con-gruent with previous studies (Lovejoy et al. 1995, Bacchuset al. 1999) carried out among patients with substanceaddiction. Clinical communities tend to consider the thera-peutic alliance as an important and robust component forthe quality of treatment. Researchers, however, have onlyrecently begun to investigate and debate this alliance asan important ingredient in substance addiction treatment(Najavits et al. 2000).

The mutual influences among patients in substanceaddiction treatment are important to discuss. Data fromthe semi-structured interviews indicated that the patientshave mutual influences on each other in terms of treat-ment motivation. The interviewed patients told that otherpatients had convinced them to stay in treatment when theyconsidered leaving the programmes prematurely. More-over, some patients told that they refused to re-enter treat-ment after a premature programme dropout because theywere ashamed and felt they had lost confidence among the

T. Nordfjrn et al.


other patients. This was also underlined by several patients,who indicated that they were more tempted to relapseor leave the facilities prematurely when other patientsexpressed similar desires.

Patients pointed to negative influences from peers whoreceived methadone or buprenorphine during long-terminpatient treatment. According to the interviewed patients,individuals who receive these medicaments during inpa-tient programmes have a lack of motivation and do con-sider medication as the most important component intreatment. In order to provide patients in OMT with com-ponents from psychosocial treatment, a recent effort in theDrug and Alcohol Treatment in Central Norway has beento enrol a number of these patients into a long-term inpa-tient facility. Within this facility they receive psychosocialtreatment among patients with other addiction patterns.The results raise a hypothesis whether treatment in anintegrated system for these patients negatively influencesthe motivation among patients who do not receive metha-done or buprenorphine. A possibility is also that patientson medical maintenance receive stigmatizing attitudes frompatients with other addiction patterns. Our data do indi-cate that out-group stereotyping may occur from patientswith other addiction patterns towards patients who receivemedically assisted treatment. Considering the importanceof interpersonal relations among patients during inpatienttreatment, research to come should further investigate howthese specific patients influence each other on motivationalvariables.

Another important aspect of the social climate was thestability of the working environments at the facilities. Oneof the more important issues underlined by several patientswere that frequent replacements among therapists nega-tively influenced their ability to establish proper therapeu-tic relations. Staff turnover represents a major threat tothe consistency, continuity and predictability of health carewithin a number of disciplines (Lum et al. 1998). Thepresent results indicated that this assumption could also bevalid for substance addiction treatment. Because the con-sistency of treatment services may be associated with treat-ment outcomes (Lamb et al. 1998), this relation should besubjected to further investigations.

In line with the differential needs among patients withsubstance addiction, the quality of therapy and interven-tions were frequently perceived in relation to levels ofmatching to specific individual problem domains. Overall,the patients were positive to therapy and interventions,and they predominantly attributed positive perceptions togroup therapy. This could be a consequence of the samplein the study. Most of the patients in the current samplewere inpatients, where social training and group therapyare the most common therapeutic approaches.

Although most patients were positive to therapy, somepatients who had been enrolled in short-term treatmentreported dissatisfaction about the provided therapies.According to these patients this was as a result of groups,which solely discussed relapse prevention techniquesrelated to alcohol, without bringing underlying psychol-ogical disorders to attention. This underscores a needfor proper screening as well as adjustments to individualproblems in the treatment of addiction disorders. A pos-sible solution is to carry out screening among patients withvalidated measurement instruments before treatment. Incentral Norway, such efforts (Stallvik 2008) are nowprioritized through a validation of The American Societyof Addiction Medicine Patient Placement Criteria for theTreatment of Substance-Related Disorders (ASAM-PPC).Despite that matching instruments have been extensivelyused in clinical settings, studies of the effects of treatmentmatching remain scarce. Clienttreatment matching mayultimately result in more relevant treatment for specificindividual problems (Gastfriend & McLellan 1997). Onthe contrary, international multi-centre studies have indi-cated that the effects of treatment matching are relativelylimited (Project MATCH Research Group 1993, Kaminer2001).

The results underlined the importance of consistentpractice of programme regulations. These regulations wereoften mentioned in negative terms by patients who prema-turely dropped out of treatment. This could be as a result ofthe fact that several of these patients had been asked toleave their facilities because they had violated programmeregulations. Moreover, the patients were concerned aboutthe lack of consistency in how sanctions were carried outwhen they had a relapse during treatment. This was as aresult of observations of other patients who were notasked to leave after such violations. The data suggest thatthe facilities should prioritize to establish consistentregulations regarding relapse, which applies equally to allpatients in the programmes.

Related to the above, some patients who had dropped outfrom the therapeutic community reported that they thoughtthe programme was too strict during early phases of treat-ment and were concerned about the loss of individualfreedom experienced in the programme. These patientsrequested possibilities to spend some time alone withoutcontinuous behavioural monitoring during early phases ofthe step-wise programme. These issues have already beenconsidered by service-delivery evaluators, and the pro-gramme has become less intensive during early phases.

The data suggested that the majority of patientsimproved their coping mechanisms in relation to substanceuse. Such improvements were reported both amongpatients who had completed treatment and among indi-



61

viduals who prematurely dropped out of their programme.This indicates that patients who prematurely leave theirprogramme also utilize abilities learnt during treatment.This is partly incongruent with Stark (1992) hypothesisthat patients who prematurely drop out of treatment havesimilar outcomes as those who have not received treatment.Perceptions among patients who prematurely dropped outof their programme indicated that the risk for extensivesubstance use was highest immediately after they left theprogramme. Several studies have demonstrated that relapseto substance use is more likely during the first months aftertreatment (Hunt et al. 1971, Brownell et al. 1986). Thefacilities should therefore strive to establish alternativetreatment and aftercare for patients who leave their pro-gramme early. Empirical data indicate that a combinationof high-intensity outpatient treatment coupled with after-care of lower intensity could reduce the risk of relapseafter treatment (Kaminer 2001). Moreover, a validapproach among some of these patients could simply be tomaintain communication after they have left the facilitiesand aim to motivate them to re-enter treatment.

Congruent with previous findings (Lovejoy et al. 1995)one of the more common domains of psychologicalrecovery was related to self-confidence and overall abilityto cope with everyday problems. Furthermore, severalpatients reported improved abilities to share their concernsand feelings with others. The latter may be related toabilities learnt during group therapy, where patients usuallylearn to become more extroverted and talkative. However,a number of patients also reported that severe psychologi-cal symptoms were present after treatment. This advocatesan integration of psychiatric services in substance addictiontreatment. According to Landheim et al. (2002) psychiatriccompetence in substance addiction treatment should beraised to the same levels as in general psychiatric healthcare. Psychological disorders may significantly worsen theprognosis of recovery from substance addiction (Grellaet al. 2001). Substance addiction and additional psycho-logical disorders should therefore be considered as interre-lated, and thus become treated within the same system.

The findings added indirectly support to previous results(Mcintosh & McKeganey 2000) that have demonstratedthat an important social strategy in recovery is to avoidformer substance abusing social networks. The interviewedpatients told that when they had to return to substanceabusing networks after treatment they perceived negativeinfluences from these networks. When the facilities andcommunity services assist patients in terms of housing, theimportance of these coping strategies should be carefullyconsidered. Patients, who did not receive assistance inrespect of housing before they left the facilities, reportedthat they were forced to come among substance abusing

friends in order to have a place to live. Thereby the patientsreported that they were exposed to substances and thusbecame ambivalent to stay abstinent. The importanceof a stable substance-free housing and meaningful occupa-tional activities for maintaining abstinence should not beunderestimated.

Limitations of the study

The present study has methodological limitations that needconsideration when interpreting the results. First, a strate-gic sample of 11 inpatients and two outpatients does notyield a representative picture of the population of patientswith substance addiction. However, semi-structured inter-views among a large representative sample would havebeen extremely resource demanding and resulted in a toocomprehensive data material for a qualitative analysis. Thepurpose of the study was to obtain a deeper understandingof how the recruited patients perceived their treatment andrecovery. Generalization from the sample to the populationof patients with substance addiction was not part of theobjective.

Second, the coding reliability was only moderate in thisstudy. Although coder bias can not be entirely excluded, thepre-definitions of categories and discussions with otherresearchers improved reliability and validity. Furthermore,Yardley (2000) argued that a too restricted coding schememay cause the researcher to be less creative and attentive tothe context of statements.

Third, it is possible that specific material occurred fre-quently because some patients were more willing to givelengthy descriptions of certain topics (Joffe & Yardley2004). The interview guide and techniques used duringthe interviews have probably reduced this influence. Thepatients were asked to reflect upon several different topics,and most of these topics included an equal amount ofquestions. During the interviews no particular topics weresystematically left uncovered by the patients, and we wereoverall impressed about the willingness and abilities thepatients had to elaborate over the different aspects in theguide. Hence, the frequencies of the reported categorieswere likely to emerge because of their relative importanceto each other, and not because the patients chose to delimittheir focus to specific topics.

Implications for clinical practice and further research

In summary, we think that the present study has beensuccessful in revealing content with implications for clinicalpractice and further research. The present study adds to thegrowing body of empirical literature, which suggests thatperceptions of treatment and recovery can not be investi-

T. Nordfjrn et al.


gated merely in relation to the sum of interventions andtherapies or a strictly limited number of outcome measures.As illustrated, patients were more preoccupied with thepossibilities to establish adequate relations to their thera-pists and other patients in treatment, when they wereallowed to talk relatively freely about their treatment per-ceptions. The results also provide an indication of thevarious domains where patients with substance addictionexperience recovery. Substance use appears to be only oneof several domains where there is potential for changes andrecovery for these patients.

Because of the high frequency of patients who strugglewith substance addiction in psychiatric wards, mentalhealth nurses will often encounter patients with addiction-related disorders. Thus, nurses in psychiatric practiceshould be provided with sufficient knowledge about howthese patients experience treatment and which life domainsthat should receive clinical focus. An implication of thepresent study is that nurses should increase their focus oncontextual variables that facilitate recovery (e.g. housingeconomy, occupation and social networks). As indicated inthe study, such contextual variables may relate to relapse.Because relapse rates tend to be higher during the firstmonths after treatment it is preferable that this is carriedout while the patients are at the facilities. Nurses shouldalso strive to establish non-confronting therapeutic alli-ances and be attentive to the mutual positive and negativeinfluences between patients with addiction-related prob-lems. The present study suggests that these social-climatefactors may be of significant importance for treatmentmotivation and persistence. A holistic approach to sub-stance addiction could be more important for outcomesthan the applied interventional techniques.

Only a few studies with qualitative methods have beenconducted to investigate positive and negative perceptionsof substance addiction treatment and recovery. Anotherapplication of the present study is that the identified

Addiction

Documents

Transcript of Addiction