Despite the broad recognition in social work that services are more effective when they are tailored to individual client needs, we have only limited evidence of the impact that services matched to client needs have on treatment outcomes. This study examines gender differences in the impact of matched services, access services, and outcome-targeted services on substance abuse treatment outcomes by using data collected from 1992 through 1997 for the National Treatment Improvement Evaluation Study, a prospective, cohort study of substance abuse treatment programs and clients. The analytic sample consists of 3,027 clients (1,105 women and 1,922 men) who reported needed services from 59 treatment facilities. Findings from the study indicate that overall programs have only limited success in targeting services to client needs, but when they do, receipt of substance abuse counseling and matched services predicts both remaining in treatment and reduced posttreatment substance use for both women and men, but especially for women.
KEY WORDS: comprehensive services; gender; need-service matching; substance abuse treatment
Research indicates that treatment approaches that provide comprehensive services to address the numerous problems that co-occur with substance abuse are most effective in reducing problematic substance use, particularly when services are targeted to meet specific client needs. These findings result from evaluations of comprehensive service programs that provide substance abuse services as well as ancillary health and social services designed to address client-identified needs (Friedmann, Hendrickson, Gerstein, & Zhang, 2004; Smith & Marsh, 2002). Although women enter substance abuse treatment with more co-occurring problems than men, it is unclear whether they benefit disproportionately when services are tailored to their needs. The purpose of this study was to examine the fundamental social work practice principle that treatment is more effective when tailored to meet client-identified needs (Berlin & Marsh, 1993; Rosen, Proctor, & Livne, 1985).
Practitioners, policymakers, and researchers have observed that medical, psychiatric, economic, family, vocational, and legal problems contribute to the development of substance abuse problems and serve as impediments to their reduction. The argument for comprehensive substance abuse services is based on the premise that substance abuse treatment is more effective when health, mental health, parenting, vocational, housing, and legal issues are addressed, along with substance abuse issues (Marsh, Cao, & D'Aunno, 2004; Marsh, D'Aunno, & Smith, 2000; McLellan & McKay, 1998). Furthermore, although the data are not consistent, a number of studies indicate that specifically matching services to clients' diverse medical, psychological, and social needs contributes positively to client retention in treatment, satisfaction, and outcome (Friedmann et al., 2004; Smith & Marsh, 2002). In studies that have not found the matching effect, researchers explained the finding by suggesting that the overall effectiveness of substance abuse treatment may be reduced if limited resources are diverted from primary substance abuse treatment activities to ancillary health and social services (Fiorentine, 1998).
Components of a Comprehensive Service Model
Studies have focused on specific types of comprehensive service strategies that contribute to improved outcomes. Among the service strategies studied are the following three: (1) outcome-targeted services, (2) access services designed to increase linkage to substance abuse services, and (3) matched services--that is, services received by clients that match their descriptions of need. In this article, in which we are concerned with the impact of substance abuse services on the outcome of reduction in substance use, we refer to substance abuse services as "outcome-targeted" services. If we were concerned with a mental health outcome, then mental health services would become the outcome-targeted service. In the present study, substance abuse counseling is the outcome-targeted service specifically related to the outcome of interest--posttreatment substance use.
Linkage or access services also have been the focus of significant research on comprehensive services. Access or linkage services are designed to increase the likelihood that a client will be able to reach or obtain the service. D'Aunno (1997) included referrals, case management, and co-located services as linkage services. McLellan et al. (1998) demonstrated the value of case managers for increasing access to services and improving service outcome. Smith and Marsh (2002) showed that access services in the forms of transportation, child care, and intensive outreach are valuable for increasing the number of services received for women with children. In this study, transportation and child care are the access services designed to link clients to health and social services.
Evidence indicates that when services are matched to specific client-identified needs, comprehensive services are most effectively delivered (Friedmann et al., 2004; Smith & Marsh, 2002). In practice, client identification of needs typically occurs as part of an assessment process. In practice research, client identification of needs often is measured by a research instrument. For example, in a randomized study of matching, McLellan et al. (1997) identified client needs using the Addiction Severity Index (ASI), an assessment interview conducted by a provider in which clients are asked to report their level of functioning in seven major areas, including alcohol and substance use. Clients in McLellan et al.'s (1997) matched group were then assigned three individual sessions in the areas of employment, family and social relations, or psychiatric health if these were identified as a need on the ASI. Matched clients were more likely than standard clients to complete treatment and to show improvement in psychiatric and employment areas. In addition, both groups showed significant reductions in substance use, but matched clients were significantly less likely to be treated again for substance abuse problems during the six-month follow-up period. In another treatment evaluation study, Hser, Polinsky, Maglione, and Anglin (1999) defined client service needs as explicit client requests for services. Their study emphasized the importance of client-identified needs and found that services meeting the needs for vocational training, child care, transportation, and housing showed beneficial effects. Smith and Marsh (2002) defined client-service matching in terms of the proportion of client-identified needs that were addressed or matched in the course of substance abuse treatment. They defined counseling services as domestic violence services and family counseling services and concrete services as housing, job training, and legal services. They also found that matched counseling services significantly predicted reduction in substance use and that matched concrete services predicted improvement in client satisfaction. Ultimately, they found that the total number of services received (matched or unmatched) had the strongest relation to treatment outcome. Overall, there has been some variability in the measurement of need--service matching across studies, but services that respond to client-specified needs appear to be related to outcome.
Service Duration as a Component of Treatment and as a Treatment Outcome
Numerous studies have shown that treatment duration is a consistent and reliable predictor of positive substance abuse treatment outcomes (Price, 1997; Simpson, 1979; Simpson, Joe, & Brown, 1997; Zhang, Friedmann, & Gerstein, 2003). Using National Treatment Improvement Evaluation Study (NTIES) data, Zhang et al. (2003) found a linear relation between duration and drug use improvement for typical treatment stays in methadone maintenance, outpatient, and long-term residential modalities. Friedmann et al. (2004) explored the relation between duration and need--service matching on the basis of the possibility that clients whose needs are met may be inclined to stay longer in treatment. There is some support for this relation in the literature. For example, Hser et al. (1999) found a significant relation between the proportion of needs matched and duration in a treatment program. Friedmann et al. (2004) found partial support for duration as a factor mediating the relation between need--service matching and drug use improvements--that is, for the possibility that individuals are more inclined to remain in treatment when their treatment needs are being met.
Measures of client retention are common proximal outcomes in social services research. A necessary condition for effective service provision is clients remaining in service long enough to benefit from treatment elements. Proximal outcomes are instrumental or intermediate variables whose attainment contributes to desired end states for clients--in this case, to reduced posttreatment substance use (Rosen & Proctor, 1981). In substance abuse treatment services research, a number of factors have been examined as predicting treatment duration, including specific client characteristics such as age, gender, race, education...