Additional file 2:Results #1 – Intervention contexts that elicit and/or support engagement

Citation / Intervention summary (Qualitative/Quantitative) / Main psychosocial/employment outcomes / Contexts that elicit and/or support engagement
Abbott et al. 1999. / Two groups were compared: 1) A Methadone Free at Intake (MFI) group; and, 2: Methadone Maintenance Transfers (MMT) or those who were on methadone for a period of time. The goal of the study was to determine if enhanced services would benefit the groups. Both groups received two treatments: a) Community Reinforcement Approach (CRA) (problem-solving skills, drug-refusal training, communication skills etc.) with referrals to the Job Finding Club; and, b) Standard Counseling (SC) with referrals to “resources in the clinic or community” (p. 131). / For both groups of clients (MMT and MFI) there were improvements in “drug, alcohol, legal, employment, social and in some measures of psychiatric distress” with the use of additional services and this continued up to the 6 month follow-up point (p. 129). At 6 months “the two groups [MMT and MFI] were comparable with regard to psychiatric problems,” legal problems and both showed decreases in depression (p. 135). / 1a) Client-centered
Both groups (MMT and MFI) were provided a variety of services and supports that appeared to be tailored, at least to some extent, to clients’ needs. For example, clients received focussed sessions on “problematic issues identified in the treatment plan” (p. 131). In addition, they were given social skills training, and there were specific sessions on problem solving and communication skills. Clients were also referred to employment agencies and marital counseling.
(Quantitative)
Abbott et al. 1998. / Three groups were compared: 1) A Community Reinforcement Approach (CRA) group (counselling including behavioral skills sessions, job finding club, etc.); 2) CRA plus relapse prevention group; and, 3) A Standard Counseling (SC) group with referrals to key resources in the clinic and community. As there were few “relapse prevention” sessions at the 6-month follow up, “the two CRA groups were combined for analysis” (p. 17). (Quantitative) / Both groups (standard and combined CRA conditions) “showed significant improvements” at the 6-month follow-up on almost all outcome variables (e.g., depression, social adjustment) (p. 27). / 1a) Client-centered
There is some evidence that in all the groups (standard and combined CRA) clients were supported in the articulation of their needs/issues and/or the development of needed skills. In addition, all groups had access to various services in the clinic and community (e.g., employment services).
Appel et al. 2000. / This study included counseling and employment services with a Vocational Rehabilitation Counselor (VRC) at clinic 1, which was compared with standard vocational-education services at clinic 2. (Quantitative) / Outcomes were measured by the amount of vocational-educational services (v-e) clients were involved with. Vocational-educational services “increased significantly in Clinic 1; net v-e involvement increased from 53 to 56% in Clinic 1 and declined in Clinic 2, 45-43%.…VRC services contributed significantly to v-e change among patients not working at admission” (p. 437). / 1a) Client-centered
Limited discussion by authors of why the intervention in clinic 1 appeared to work. It appears that services were somewhat tailored to patients’ situation (e.g., if “ready” for employment given intensive counselling) although it also appears it was based, at least in part, on counselors’ judgements of patient readiness and assessment of the clients’ vocational-educational prospects.
Aszalos et al.1999. / Evaluation of a 6-month outpatient program with methadone therapy. Group and individual therapy, case management (e.g., assistance with housing or legal situations) and access to services (e.g., psychiatric consultations were available). No control or comparison group. (Quantitative) / According to the researchers, “Patients improved deficits in health and social indicators by obtaining medical coverage, keeping outpatient medical appointments, and improving their housing conditions” (p. 149). / 1a) Client-centered
The researchers argue that they “encouraged patient investment and ownership” suggesting that there was some interest in the clients’ needs and issues (p. 151). In addition, “An optional weekly spirituality group was…initiated upon patient request” (p. 152).
1b) Socio-economic conditions
Responsiveness to clients’ socio-economic lives (e.g., case management assistance with housing and legal situations); given “information on preferred shelters and accessing emergency food stamps”; assistance with transportation (bus tickets) and if childcare was unavailable they could bring child with them to the intervention (p. 152).
Bigelow et al. 1980. / Four groups were compared: 1) Contingency Management group; 2) Emotionally-based Behavior Therapy group; 3) both of these; and, 4) a control condition receiving counseling (supportive decision making). (Quantitative) / There were no significant differences found between treatment groups. The researchers state that, “No differential effects of the four assigned treatment modalities were evident in between-group comparisons on the various outcome measures. Overall, there was little average change in the treated group over the 6 months of their participation” (p. 432). / 1a) Client-centered (Lack of)
Some limited evidence pointing to why the interventions did not work. There was good retention (78% remained in treatment for 6 months or more), but it appears that the context may have not been client-centered enough as it was the counselors who “selected specific treatment goals, and designed and implemented treatment techniques” (p. 430). The supportive decision-making counseling, which all participants received (including control group), may have been what all the participants wanted, and hence no significant differences between groups. This supportive counseling “consisted of here-and-now based discussion of [a] client’s life situations, feelings, problems and alternatives, with counselors providing both suggestions and emotional support” (p. 430) suggesting that it was very client-centred.
Carpenter et al. 2006. / The intervention involved behavioral therapy and contingency management through individual counseling. No control or comparison group. (Quantitative) / According to the researchers, “Approximately 48.3% of the patients demonstrated at least a 50% reduction” in self-rated depression and clinic rated depression at 12 weeks relative to baseline (p. 544). / 1a) Client-centered
Intervention appears to have been at least somewhat tailored to clients’ psychosocial needs/skills (including need for skill development) with therapy sessions on “increasing activities in rated important life areas [and] developing skills to increase activities…” (p. 543).
Cohen et al. 1982. / Phase I: 6-week seminars on antecedents, consequences, and control of drinking. Phase II: Two experimental groups: 1) An Abstinence Oriented Insight group therapy; and, 2) A Drinking-oriented Behavioral Modification group therapy were compared to 3) a control group (individual counseling sessions). / No difference between the two experimental groups and control group on such indices as productive activity, days worked, or “days of hospitalization per quarter” (p. 358). The researchers note that “the results of this study document the generally poor compliance of OA [operative alcoholics] in seeking and maintaining therapy for their alcoholism. It is of interest that there appears to be considerably less resistance in their participation in treatment for their narcotic addiction, as the retention rates of OA did not differ from NA [non-alcoholics]” (p. 360). / 1a) Client-centered (Lack of)
This study provides some evidence supporting our finding that if an intervention is not client-centered, or clients do not have an opportunity to articulate their needs/issues, engagement (including attendance) will be low. There was good attendance with the methadone program but not the treatment intervention (e.g., only 18 out of 84 participants in the treatment groups were involved), suggesting clients were not interested in the intervention which focused on therapy for alcoholism. Also, the seminars may not have allowed the clients to be actively involved in dealing with their particular issues so they may not have been of interest.
(Quantitative)
Connett 1980. / Counseling with two different types of counselors: 1) paraprofessional (group CGA); and 2) professional (group CGB). (Quantitative) / Employment for patients with paraprofessional counselors “revealed a greater percentage on full-time employment” but those with professional counselors “showed a larger combined percentage of occupational activities when ‘school-training and homemakers’ were totalled” (p. 587–588). / 1c) Relationships
Although the results were mixed, the findings indicate that a greater percentage of clients counseled by paraprofessionals obtained full-time employment possibly because of a more supportive counselor-client relationship given that the paraprofessionals had more experience or understanding of this population than the professional group. Indeed, the researchers suggest that, “the closer social environmental identification and experiences of CGA [paraprofessional] counselors with this type of patient population may have been more of an influencing factor upon patient progress in the short run than had been anticipated” (p. 589).
Coviello et al. 2004. / Comparison of two groups: 1) Vocational Problem Solving Skills (VPSS) group (based on the interpersonal, cognitive, problem-solving [ICPS] theory); and, 2) a control group using the same ICPS theory but with a focus on drug use.
(Quantitative) / Throughout the intervention, clients had a high level of motivation for finding work (an average of 7.70 out of 10) (p. 2315). However, according to the researchers, “Overall, there were no differences between conditions in motivation or action steps for obtaining employment… (p. 2317). / 1a) Client-centered
1b) Socio-economic conditions (Lack of)
The VPSS intervention was tailored to allow a client to “think through his/her own problems and select a range of action-oriented steps that could be helpful in reaching a realistic goal” (e.g., employment) (p. 2311). It appears, therefore, to be client-centered. (The control group used the same approach but was focused on drug use). However, the lack of -attention to clients’ socio-economic conditions appears to be a key factor in why there were no differences in outcomes between the groups. That is, clients wanted “off the books” employment rather than taxable employment. The researchers note that, “For many of the clients the primary aim of obtaining employment was to meet a financial need. Participants obtained sporadic employment (day jobs) as a means to cover daily expenses” (p. 2318). The researchers note that, “attempting to measure activities and motivation that did not have adequate validity or appropriately represent the client’s lifestyle and desire to work” may have been a contributing factor to the poor outcomes (p. 2320). The researchers suggest for future studies to consider that “taxable employment with little flexibility may not be a desired or attainable outcome due to the complexity of client lifestyle and the unavailability of private health insurance to pay for methadone treatment” (p. 2321).
Coviello et al. 2009. / Two groups compared using manual based Interpersonal Cognitive Problem Solving (ICPS) theory: 1) A control group using ICPS was centered on drug counselling; and, 2) an experimental group using ICPS focused on integrated employment and drug counselling. (Quantitative) / According to the researchers, “While there were no differences between the integrated and control conditions, both groups showed a significant improvement in employment outcomes…at the six-month follow-up” (p. 189). / 1a) Client-centered
Both groups appeared to be client-centered as the first component of each group was to assess clients’ needs, working with the client to understand barriers to employment/ recovery, developing an action plan etc. Indeed, in both groups there appeared to be support for the client to think through “his/her own problems and select a range of implementable options that could potentially be helpful in reaching a realistic goal” (p. 190). The authors argue that one of the reasons why there was “no significant treatment effect between groups” is probably because “both groups received the problem-solving intervention, [and] the control group could have generalized these strategies to finding work” (p. 195).
Dansereau et al. 1996. / Two groups were compared: 1) Individual and group counseling utilizing node-link mapping/mapping enhanced counseling; and 2) a control group receiving standard counselling. (Quantitative) / Clients in the mapping group had “missed fewer scheduled counseling sessions, and were rated more positively by their counselors on rapport, motivation, and self-confidence” (p. 374). / 1a) Client-centered
The mapping intervention appears to allow the client to articulate their needs/issues as maps are used to “represent interrelationships comprising personal issues and related plans, alternatives or solutions visually” that the client and counselor discuss (p. 364). Each map has nodes that contain “thoughts, actions, or feelings, and named ‘links’ are used to express their interrelationships” (p. 364). Hence, some of the improvements of the mapping group over the control group may have been due to the fact that mapping allowed clients to visually focus on articulating their issues.
Farabee et al. 2002. / Four groups were compared: 1) Cognitive-behavioral Therapy (CBT) which used group counseling; 2) Contingency Management (CM) group with individual meetings and vouchers for stimulant-negative urine samples; 3) combination of both CBT and CM; and, 4) a control group, methadone maintenance treatment only. (Quantitative) / Participants “who had been exposed to CBT reported engaging in drug-use avoidance activities more frequently than did subjects assigned to either the CM or control conditions…at treatment end and at the 52-week follow-up contact” (p. 348). However, at the 26-week follow-up the difference in drug-use avoidance activities was not statistically significant. According to the researchers, “While participation in CBT treatment increased the likelihood that participants would engage in one or more of these avoidance activities, it appears that the subjects in the non-CBT conditions adopted some of these activities as well” (p.349). Drug use avoidance activities included exercise, avoiding drug-using friends etc. / 1a) Client-centered
The CBT treatment (groups 1 and 3) had more positive outcomes at treatment end and at the 52-week follow up than the CM or control groups, and this may have been because in the CBT groups clients were encouraged to articulate how the topic introduced was relevant to them (p. 346).
1b) Socio-economic conditions
Clients in the CM group also had positive drug-use avoidance scores. This intervention awarded clients with vouchers. The researchers argue that, “As the voucher account increased in value as a result of stimulant-free urine samples, participants were encouraged to ‘spend’ their savings on items that could support drug-free activities. Although participants were strongly encouraged to use the voucher earnings to engage in new prosocial, non-drug-related behaviour, this group of patients was far more interested in using their earnings for subsistence items” (p. 346). These subsistence items included such items as food (restaurant/fast food certificates, grocery store vouchers), as well as clothes for themselves or their children and gas. It appears, therefore, that the voucher system may have supported some engagement with the intervention.
Glickman et al. 2006. / All participants underwent a peer-based 12-Step self-help program with spiritual underpinnings, training in running peer-led groups, and attended 12-Step oriented meetings. No control or comparison group. (Qualitative) / With this program, “the transition into a leadership/helper role appears to mark an important life transition on the way to a successful and new, more honest, spiritually-anchored phase of life” (p. 533). The researchers argue that taking on this leadership role allowed the clients “to assume a new, higher function in a struggle with the addiction” (p. 531). Participants felt a transformation occurring that was related progressively to a “more secure recovery” (p. 532). / 1a) Client-centered
The program was client-centered insofar as counselors supported the clients in the development of new skills, and it was “designed to afford an opportunity for self-examination” (p. 531).
Joe et al. 1997. / The intervention compared: 1) An Individual and group counseling group (utilizing node-link mapping); and, 2) a control group with standard counseling. (Quantitative) / According to the researchers, 12 months after the treatment ended the outcomes were mixed. The mapping group was less likely than those in standard counseling to report illegal activity, being jailed or arrested. Yet, “measures of self-esteem, decision-making confidence, and hostility showed mapping clients tended to rate themselves more poorly than standard clients….However, overall ratings at follow-up were moderately positive on all measures in both counseling modalities” (Discussion para 3). / 1a) Client-centered
This study suggests that articulating one’s issues through mapping may have some negative outcomes as “mapping might have led clients to see their psychological and social strengths and weaknesses in a more critical (and perhaps more realistic) light” (Discussion para 3).
Joe et al. 1994. / Two groups were compared: 1) Individual and group counseling sessions utilizing node-link mapping to; and, 2) a control group with standard counseling. (Quantitative) / Clients in the mapping group had higher counselor ratings than those in the control group on rapport, motivation and self-confidence (p. 404). / 1a) Client-centered
Mapping was used to help clients represent interrelationships between their ideas, feelings and experiences. Clients worked with the counselors in the development of the maps, and in this intervention the “goals were mutually agreed to by client and counselor in light of the client’s unique history and needs”, which demonstrates clients’ involvement in identifying or articulating their psychosocial issues (p. 395). It appears that the better outcomes for the mapping group were, at least in part, because the visual tool allowed the mapping group to articulate their issues and concerns.
Kidorf et al. 1998. / This intervention involved a mandatory employment programme based on contingency management (e.g., more intensive counseling if did not meet employment goals). The intervention included counseling to help find employment (paid or volunteer). Two types of counseling were offered, individual and group. No control or comparison group. (Quantitative) / According to the researchers, “Seventy-five percent of the patients secured employment and maintained the position for at least 1 month. Positions were found in an average of 60 days. Most patients (78%) continued working throughout the 6-month follow-up” (p. 73). / 1a) Client-centered
It appears that the intervention was client-centered as, “Group counselors spent considerable time…developing strategies for seeking employment and other constructive activity, and praising efforts toward meeting the goal” (p. 78). In addition, clients’ were supported in skill development as individual counselors assisted clients in “completing applications, creating resumes, and identifying job and volunteer openings” (p. 78).