Addictive Behaviors, Vol. 19, No. 3, pp. 343-348. 1994 1994 Elsevier Science Ltd

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PHYSICAL PROXIMITY AS A POSSIBLE FACILITATOR IN POST-DETOXIFICATION TREATMENT-SEEKING AMONG

CHEMICALLY DEPENDENT VETERANS

STEVEN M. ROSS*? and CHARLES TURNER*S *Department of Veterans Affairs Medical Center

tDepartment of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT *Department of Psychology, University of Utah, Salt Lake City, UT

Abstract - The transition into rehabilitative treatment following detoxification is a critical event for most chemically dependent individuals. A host of factors may enhance or impede this transition, yet little or no research has been done to shed light on this issue. This paper presents the results of the fortuitous changing of one variable which appeared to increase the likelihood of a successful transition, namely, the degree of physical proximity of the detox program and the rehab program. Results indicated a significantly greater proportion of patients successfully making the transition from detox to rehab when the programs were very close proximally than when they were less close. The role of possible patient-to-patient modeling effects was discussed.

Detoxification from chemicals is recognized as the first necessary step in treatment for most substance use disorders involving mind- or mood-altering substances. Fol- lowing detoxification, active treatment typically begins focusing on helping the indi- vidual learn to live a sober or drug-free lifestyle. By definition, then, a critical step or transition occurs between the detoxification phase and the more active treatment phase for substance use disorders. These observations suggest that it is important to help patients make the transition from detoxification to active treatment. Unless the transition is successfully negotiated, patients may leave treatment prematurely, that is, not enter the active treatment stage following detoxification. This transition fail- ure occurs all too frequently (Novick, Hudson, & German, 1974).

Surprisingly little research has examined the transition phenomenon. As a result, many questions remain as to the best way to encourage patients to seek active treatment following the detoxification period, and how to maximize the chances that the patient will, in fact, go into active treatment after detoxification. Several complex interacting variables are involved in the transition process. Some examples of these variables are the patient’s initial motivation for seeking detoxification and readiness for change (Prochaska & DiClemente, 1986), outside pressures for continuing versus terminating treatment, the patient’s beliefs about treatment and the perceived need for further treatment (e.g., some patients may believe detoxification is treatment), and the degree to which the patient may be cognitively or emotionally impaired (McLellan, Luborsky, Woody, O’Brien, & Druley, 1983; Walker, Donovan, Kivla- han, & O’Leary, 1983). In addition to patient factors, interpersonal and contextual factors may also play a role in the transition process. Interpersonally, is it better to have peers who are already in treatment attempt to persuade the reluctant patient about the benefits of continuing treatment, or would staff do a better job? Data obtained by Craige and Ross (1980) using a pretherapy training paradigm indicated

Requests for reprints should be sent to Steven M. Ross, PhD. Department of Psychiatry, University of Utah School of Medicine, 50 N. Medical Dr., Salt Lake City, UT 84132.

343

344 S.M.ROSSandC.TURNER

that a peer-modeling videotape procedure was significantly more successful than more traditional films depicting the need for treatment in getting patients to engage in continuing treatment after detoxification. Contextually, would it be more effective to hold these discussions on the detox unit itself or on the treatment unit where patients could see the physical characteristics of the program which is being discussed’?

One important aspect of contextual factors may have to do with the geographical location or physical proximity of the detox and treatment facilities in relation to each other. For example, aftercare follow-through is enhanced if the aftercare is provided by the same facility that provided inpatient treatment (Chvapil, Hymes, & Delam- stro. 1978). In addition, when patients live at a greater distance from the treatment program, referral to closer facilities enhances continued involvement (Prue, Kean, Cornell. & Foy, 1979). These results suggest methods to improve the detox-to- treatment transition. Would more patients be interested in continuing treatment if the treatment was proximal to the detoxification setting’? One might expect a higher rate of continuing treatment under these circumstances for several reasons. First, close physical proximity might allow anxious or mistrustful patients an opportunity to see firsthand the nature of the treatment program. Second, close proximity might also foster social interaction between patients and between patients and staff of the active treatment program. This interaction establishes an opportunity for questions and answers, rapport building, and modeling of peer treatment-seeking behaviors. Thus, if all else were equal, one might expect an increase in continuing treatment activity among patients making the transition from detoxification to active treatment if the two programs were located in close physical proximity to one another.

This report describes the results of the fortuitous moving of a detoxification unit and an active treatment unit because of changing space and staffing requirements in a Department of Veterans Affairs medical center. Fortunately for our purposes, these moves permitted an examination of the role of the proximal/distal variable in rates of treatment-seeking during the critical transition period. The present study examined the hypothesis that the more proximal the Detoxification Unit was to the Rehabilita- tion Unit, the greater would be the number of patients making the transition from detox to active treatment.

METHOD

Subjects

The records of five hundred seventy-three patients who completed inpatient de- toxification in a western U.S. VA medical center were reviewed for outcomes during five discrete intervals of time. Initial data entry occurred by means of the routine clerical process which is part of agency policy and procedure. The discharge status of all patients who are discharged or transferred from any medical center inpatient unit is routinely recorded by the ward clerk. Thus, it was possible to determine from the existing medical record which patients were transferred to the treatment pro- gram, which patients were discharged and referred to the outpatient program, and which patients were discharged without a referral for further treatment. Approxi- mately 98% of the patients were male. Mean age of patients was 48 years (range 26 to 78). and mean education level was 12.3 years (range 7 to 18). Approximately 70% of patients were alcoholic, 18% poly-substance users, and 12% stimulants or narcotics users. Approximately 35% of the patients were married.

Design In order to determine if the independent variable, proximity of the Detox and

Rehab Units, influenced the number of transfers between the two units (the depen- dent variable) several comparisons were made at different times under varying de- grees of proximity. The different times were dictated primarily by the exigencies of Operation Desert Storm which resulted in a temporary loss of staff for 3 months. The loss of these staff, who were called up for National Guard duty, necessitated that the two units temporarily occupy the same ward (the High Proximity condition [HP]) in order to keep both units operational and to utilize existing staff most effectively. This condition lasted 3 months. In order to make comparisons, then, 3-month blocks of time were subsequently examined. Specifically. transfer rates were examined for 3- month blocks of time (a) prior to Desert Storm, (b) during Desert Storm, and for three blocks after Desert Storm.

During the interval of time prior to Desert Storm, the two units were located in two separate buildings on the medical center grounds, constituting the Low Proximity condition. During the period immediately following Desert Storm, the two units were relocated on two adjoining wards, constituting the Medium Proximity condition. Two 3-month blocks of time were examined in this condition.

Thus, the physical proximity between the Detoxification Unit and the Inpatient Rehabilitation Unit varied by three degrees of closeness during five discrete time intervals. During the intervals that the proximity varied between the Detox and the Rehab Units, however, the distance to an Outpatient Substance Abuse Clinic re- mained the same. The clinic was located two and one-half miles away from the medical center grounds nearer the central city area. Thus, several comparisons were made in order to determine what the possible role of changes in physical proximity per se on the transfer rate might have been: (a) The total number of patients who were discharged without either an inpatient or outpatient transfer was used as a baseline against which to compare outpatient transfers and inpatient transfers; (b) The number of outpatient transfers and inpatient transfers were analyzed over time in order to determine if there were significant deviations during any 3-month interval; and (c) If a significant deviation occurred in the inpatient referral rate, it was com- pared with the other two rates to increase confidence that it was due to physical proximity per se.

RESULTS

The first hypothesis to be examined was whether the rates of transfer status (Transfer to Inpatient vs. No transfer to Inpatient) from detox to treatment varied across the five time periods. The patients included in this analysis were those who transferred to inpatient facilities (n = 145) and those who did not transfer to Inpatient (n = 380). The hypothesis was examined using a 2 x 5 (Transfer status x Time period) x’ test. The results indicated that the rates of transfer to inpatient status did vary significantly by time period, x?(4) = 12.91, p 5 .Ol. A 2 x 2 (Transfer status x

Time period) planned comparison indicated that the transfer rate during the High Proximity period (49.0%) was significantly different from the average of the other four time periods (30.5%), x?(l) = 12.38, p 5 .0004. A Bonferroni adjusted signifi- cance level (a/# comparisons) adjusted the study-wide chance error rate for the multiple comparisons being performed. Another planned comparison indicated that the transfer rates for the four periods of medium to low proximity (periods I, 3. 4,

346 S. M. ROSS and C. TURNER

Table I. Mean 3-month transfer discharge rates as a function of physical proximity

Proportion of transfers/discharges

Proximity of Detox Unit to Rehab Unit

To the community

To Rehab Unit

To outpatient treatment

Low .68 .29 .03 High .47 .49 .04 Low .58 .28 .I3 Medium .66 .37 .o:! Medium .61 .37 .I2

and 5) were not statistically significantly different from one another, ~‘(3) = O.SS, p 5 .90. The inpatient transfer rates for the Medium Proximity and Low Proximity conditions also were not significantly different x2( I) < I .O.

Some of the patients transferred to an outpatient facility rather than the inpatient facility. These transfers provided a comparison group with which to determine whether the higher rate of transfer to inpatient facility in the High Proximity period was due to some transitory effect of Desert Storm. The present analysis only consid- ered patients who returned to the community (tz = 345) or who transferred to outpa- tient facilities (tl = 35). A 2 x 2 (Transfer status X Time period) planned comparison indicated that the transfer rate during the High Proximity period (8.0%) was not significantly different from the average of the other four time periods (9.4%). x2( I) = 0. IO, p 5 .75. These results are presented in Table 1 and Figure I.

Transfer rate from the Detox Unit to the Inpatient Rehab Unit was fairly constant in the Low Proximity and Medium Proximity conditions, averaging approximately 30%’ but increasing to approximately 50% during the High Proximity condition. As far as can be determined, there were no other changes that occurred that might account for the difference in transfer rate other than the proximity variable. In other words. staff presumably did not change their method of attempting to interest pa- tients in further treatment, inpatient or outpatient, during any of these time intervals, and events occurring simultaneously (e.g., Desert Storm), did not appear to play a role as evidence by the fact that the transfer rate to the Outpatient Unit did not change significantly during the same interval. A more convincing test. of course, would be a return to the High Proximity condition to see if the results are replicated. The latter was not feasible, since further moving of programs. patients, and staff would be too disruptive for purely experimental manipulation purposes. It may be feasible, however, to test the proximal/distal effect more directly in future research. One might, for example. transfer patients who are sufficiently medically stable to the Rehab Unit prior to completing their detoxification to determine if more of these patients indicate an interest in further treatment compared to those patients who are not exposed to the Rehab Unit prior to discharge. Another possibility might be to have the detox and rehab patients share some facilities, for example, a dayroom. to encourage peer interaction. modeling effects. etc.

Transfer rates from detox to treatment 347

0.7

0.6

0.5

0.4

PROPORTION OF

DISCHARGES

0.3

0.2

0.1

0

l-

I-

LOW HIGH LOW

PROXIMITY

MEDIUM MEDIUM

A To the Community

+ To Inpatient Rehab

I To Outpatient Treatment

Fig. I. Detox transfer rates as a function of proximity to Inpatient Rehab Unit.

The fact that more patients indicated an interest in further inpatient rehab treat- ment during the High Proximity interval resulting in more transfers during this time period is interesting because it raises the question of what exactly might have oc- curred during the high level of physical proximity. For example, did the High Prox- imity condition enable patient peers to model more treatment-seeking behavior? Were detox patients’ fears of further treatment allayed? Based on the earlier findings of Craige and Ross (1980), modeling effects could well have been a factor. Future research could profitably focus on this aspect in an attempt to enhance it and use it therapeutically.

REFERENCES

Chvapil, M., Hymes, H., & Delamstro, D. (1978). Outpatient aftercare as a factor in treatment outcome: A pilot study. Journal qf Studies on Alcohol, 39, 540-554.

Craige, F. C., & Ross, S. M. (1980). The use of a videotape pre-therapy training program to encourage treatment-seeking among alcohol detoxification patients. Behuvior Thercrpy, 11, 141-147.

348 S. M. ROSS and C. TURNER

McLellan. A. T.. Luborsky, L., Woody. Ci. E.. O’Brien. C. P.. 6t Druley. K. A. (1983). Predicting the response to alcohol and drug abuse treatments: Role of psychiatric severity. A~c~/livc~.s ctf‘ Gener-cl/ P.c.~&irrrr:,, 40, 620-625.

Novick, L. F., Hudson, H., & German. E. (1974). In-hospital detoxification and rehabilitation of alco- holics in an inner city area. Amrrictr~~ Jotrmtrl of‘frthlic~ Health. 64. 1089-1094.

Prochaska. J. O., & DiClemente. C. C. (1986). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.). 7’recrting trddic/iue hc~/r~ruior,s: P,r,c~e.~.\c,.\ c?f‘ c,hrrnge (pp. 3-27). New York: Plenum.

Prue, D. M.. Keane. T. M., Cornell. J. E., & Foy. D. W. (1979). An analysis of distance variables that affect aftercare attendance. Cwrr~~rtnit~ Mcntc~l Hcc~ltlr Jor~r~~rrl. 15. 149- 154.

Walker. R. D.. Donovan, D. M.. Kivlahan. D. R., &O’Leary, M. R. (1983). Length of\tay. neuropsycho- logical performance. and aftercare: Influences on alcohol treatment outcome. Jotrrnctl of‘Ccmsrr/rin,g

trnd C/irric,tr/ P.~yc~/lo/og,v. 51. 900-91 I.