Clients’ Experiences and Satisfaction with an Integrated Intensive Outpatient Program for Substance Use Disorders

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Clients’ Experiences and Satisfaction with an Integrated Intensive Outpatient Program for Substance Use Disorders

https://doi.org/10.21203/rs.3.rs-4731174/v1

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Comorbidity between substance use disorders and other mental health conditions is common, yet existing treatments often fail to address its full spectrum. Opportunities for integrated treatment are limited, and the effects of such treatment remain relatively unexplored. This study aims to describe the experiences of individuals with substance use disorders who received treatment at an integrated intensive outpatient addiction-care clinic. Utilising a survey with quantitative measures and qualitative questions with free-text responses, the experiences of 65 clients who had completed the programme between 2015 and 2021 were evaluated. The findings indicated that most clients were highly satisfied with the treatment. The analysis revealed three main categories: strong relationships and a comprehensive treatment programme; engaged and knowledgeable staff who lead with warmth; and self-development through new experiences. Overall, clients reported high levels of satisfaction with the integrated intensive outpatient programme. Despite these positive outcomes, this study highlights the need for further research on, knowledge about and competence in the development of integrated treatment interventions for individuals with substance use disorders.

Addiction care

Cognitive behavioural therapy (CBT)

Comorbidity of mental disorders

Client satisfaction

Intensive outpatient programme

Substance use disorder (SUD)

Clients experienced satisfaction with the treatment programme and transformative processes.
Group sessions facilitated the building of connections and relationships among clients.
Engaged and knowledgeable therapists played a significant role.
Clients gained new experiences and improved their self-image.
The opportunity for self-reflection provided clients with a fresh start in life.

According to the United Nations (n.d.), in 2019, a global population exceeding 35 million individuals experienced drug use disorders, but only one out of every seven persons received treatment [1]. In Sweden, where this study was conducted, 1.8% of the population had a substance use disorder in 2017 [2]. Approximately 50% of individuals diagnosed with a substance use disorder specifically, alcohol and/or drug dependence often experience comorbidity with other psychiatric illnesses or conditions. It has also been demonstrated that individuals with mental health issues are at an increased risk of developing substance use disorders [3]. In Sweden, the opportunities for receiving treatment for comorbidity, where an individual receives treatment for both their substance use disorder and psychiatric illness, are relatively limited. This has an impact on treatment outcomes. This study aims to describe how individuals with a primary diagnose of substance use disorders perceived an integrated intensive outpatient addiction-treatment intervention. To contribute to the knowledge and evidence regarding alternative treatment options, it is crucial to study the experiences of individuals with substance use disorders. Furthermore, there is a need for increased knowledge among professionals who work with and encounter individuals with substance use disorders, such as those in healthcare and social services.

Substance dependence can be characterised by its potential to give rise to social problems, such as problematic relationships and difficulty in completing major work or school tasks [4]. The risk of using alcohol and drugs has been shown to be higher among individuals with psychiatric disorders, such as anxiety disorders, depression, bipolar disorder, schizophrenia and obsessive-compulsive disorder, than among those without psychiatric diagnoses [3]. Today, drug use is becoming more normalised, and drugs are increasingly accessible, with easy methods of acquisition, such as through the internet [5]. While drug use has increased, alcohol consumption in Sweden has decreased. Among adults, 4% of the population had alcohol dependence in 2017. Although one study revealed no significant gender difference in Sweden, more men than women still have alcohol dependence [2].

Treatment of Substance Use Disorders: Psychological and Psychosocial Interventions

The National Board of Health and Welfare [6] recommends integrated programs, medication and psychological and psychosocial interventions for the treatment of substance use disorders with concurrent psychiatric issues. Two of the psychological and psychosocial interventions that may be included in integrated care are the 12-step programme and relapse prevention [6]. Both the 12-step programme and cognitive behavioural therapy (CBT) are standardised treatment methods within the field of substance abuse and addiction care and are offered at multiple locations throughout the country [7].

The 12-step programme is based on the 12-step programmes of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). AA and NA are non-profit self-help organisations for individuals with substance use issues through which they can support each other in maintaining sobriety. The treatment consists of 12 steps through which the individual is expected to progress during the treatment process. Some of the steps involve acknowledging powerlessness over the substance, examining personal values, admitting shortcomings and making amends to individuals harmed by one’s substance use [8]. The 12-step programme largely focuses on processing one’s relationship with substance use and becoming aware of the barriers to recovery, and according to Donovan et al. [8], individuals are expected to abstain from substance use, attend meetings and be willing to seek help. The programme is implemented in both public and private addiction treatment settings and is used in both inpatient and outpatient care. In outpatient care, the programme continues for 1 year, with daily group meetings in the initial months and longer intervals between meetings as treatment progresses. In inpatient care, the treatment follows a more intensive schedule, including 6 weeks of daily group therapy and 1 year of follow-up care [7].

CBT is a psychotherapeutic treatment method that has been shown to be effective for individuals with substance use disorders and comorbid psychiatric conditions [6]. During the 1970s, classical CBT emerged, focusing on identifying, addressing and modifying undesirable behaviours and negative thoughts [9]. Our behaviour is not primarily based on an actual event but rather on our perception of the situation. This perception, or conceptualisation, can be divided into three categories: core beliefs, dysfunctional assumptions and negative automatic thoughts [10]. By identifying one’s thoughts and emotions and becoming aware of one’s behaviour, one develops the ability to manage the problem using new strategies. In CBT, the management of thoughts and behaviours is referred to as coping, which encompasses the strategies used to control negative thoughts and behaviours [11]. CBT is a commonly used treatment approach in the field of substance abuse and addiction. The goal is to help clients develop more adaptive ways of thinking and acting that lead to improved mental health and well-being.

Complementary healthcare methods can be used in conjunction with the aforementioned treatment approaches. Various complementary methods are employed to alleviate symptoms associated with substance use disorders, depression, anxiety or stress when conventional treatment is deemed insufficient [12]. The application of complementary methods within healthcare is limited due to the requirement that all healthcare be based on scientific evidence and proven experience, as stipulated by the Swedish Healthcare Act [13]. Although the evidence for several complementary methods is currently limited, where evidence exists, such methods may only be used in consultation with the individual receiving care under the condition that they do not replace other forms of care and treatment.

Substance use disorders involve harmful substance use and dependence. Co-occurring psychiatric conditions are commonly present in individuals with substance use disorders, often requiring multiple interventions, such as social support, psychological support and medication. It is important to adopt a person-centred approach for these individuals to provide treatment that addresses their overall situation. However, opportunities to receive integrated treatments are limited. The current offerings in addiction care often consist of a combination of medical treatment and CBT, with little opportunity for participation in a programme that includes both psychological and psychosocial treatments. The inadequate availability of integrated treatments is a weakness in addiction care. The problem is that individuals with substance use disorders are not offered treatment options to the extent necessary to address their overall co-occurring psychiatric condition. This may be due to a lack of sufficient evidence regarding integrated treatment programs or the need to evaluate the experience of CBT-based integrated intensive outpatient treatment for individuals with substance use disorders. It is important to study this aspect to enhance the knowledge and competence of healthcare and social service professionals who encounter individuals with substance use disorders and co-occurring psychiatric conditions in their work.

The aim of this study is to describe how individuals with substance use disorders experienced the treatment provided at an integrated intensive outpatient addiction care clinic.

Study Design and Procedure

This study utilised a survey assessing both quantitative and qualitative information. To ensure the quality of the integrated intensive outpatient care treatment, clients were asked to complete this evaluation (survey) after completion of the treatment.

Context

A structured treatment programme is offered for adults with substance use disorders at an addiction outpatient clinic in western Sweden, based on the principles of CBT. The treatment focuses on exploring how individuals truly desire to live their lives, their current lifestyle and their inner experiences. The outpatient programme includes four months of intensive integrated treatment conducted 5 days per week and includes psychoeducation, group intervention, group sessions, individual therapy sessions, yoga, mindfulness, tai chi and acupuncture. The goal of treatment is to assist individuals in attaining more meaningful lives. Through appropriate support and a psychological approach to treatment, individuals learn to navigate life difficulties and address the origins of these difficulties [14].

Participants

Between 2015 and 2021, 117 individuals started treatment, 52 of whom did not complete the treatment or the survey for the present analysis. Therefore, the study population consisted of 65 adult individuals who had completed integrated intensive outpatient treatment and questionnaires.

Data Collection

The questionnaire consisted of six questions, the first three of which were answered on a Likert scale. Clients were asked to rate their experience on a numbered scale from 0 (not satisfied at all) to 10 (very satisfied). The remaining three questions were open-ended, allowing clients to write about their experiences of the treatment. There was also an opportunity to provide additional valuable information and comments about their experiences in the final question.

Data Analysis

Descriptive Statistics

The clients answered three questions on an ordinal scale, and the responses were compiled for reporting using descriptive statistics. SPSS version 29 was used to calculate the mean (M), median (Md) and standard deviation (SD).

Qualitative Content Analysis

The analysis of the open-ended questions was inspired by manifest content analysis, according to Graneheim and Lundman [15]. The data consisted of 59 questionnaires. The analysis process resulted in three categories (Table I).

Table I. Overview of the analysis process

Meaning unit	Condensed meaning unit	Code	Category
This has been a highly educational experience, providing a wealth of tools not only for sobriety but for life in general. We have formed a wonderful group, and although there may be individuals with whom I don’t feel secure at times, that has not been the case here.	Enriching and supportive, both for sobriety and life. This has been a wonderful group in which I have felt safe.	Satisfied with the experience of the treatment programme and the relationships that have been formed	Strong relationships and a comprehensive treatment programme
The healthcare staff have been crucial for me, looking straight into my addiction persona and helping me unveil everything, without keeping any secrets.	The approach of the healthcare staff has been important in understanding the entirety of my issues.	Appreciate the healthcare staff	Dedicated, knowledgeable personnel who lead with warmth
The healthcare staff have helped and supported me, guiding me to think differently.	They have assisted me in thinking differently.	New ways of thinking	Personal development through new experiences

Descriptive Statistics

The participants (N = 65) were asked to rate their experiences of their time spent at the treatment facility and in the programme, as well as their perceptions of the information provided. The results indicated that the participants were satisfied with their experiences of integrated intensive outpatient treatment. Of the study population, 65 participants (100%) responded to question 1 (How did you experience your time at the clinic?). The mean score for the measured experiences of time at the treatment facility was 9.4 (SD 1.20). Moreover, the majority of participants (70.8%) reported being very satisfied (rated 10) with their time at the clinic. The minimum value for this response was 5. Figure I presents the participants’ experiences of the programme (question 2), with a mean score of 9.1 (SD 1.3), indicating a positive experience. All participants responded to the question about their experiences of the programme, and the results showed that more than half (65%) were very satisfied (rated 10). The minimum value for this response was 5. Question 3 assessed how well the participants felt they had absorbed the information provided during the programme. Forty participants (97%) responded to this question, with a mean score of 9.3 (SD 1.17). Sixty-one per cent reported being very satisfied (rated 10), indicating that the information provided to the participants had been conveyed in an understandable manner. The minimum value for this response was 6.

Figure I. Participants’ experiences of 4 months of integrated intensive outpatient treatment, presented using means and medians on a scale from 0 to 10 (0 = not satisfied at all, 10 = very satisfied) in relation to their level of satisfaction.

Qualitative Content Analysis

The results of the qualitative part of the study are presented below. The analysis resulted in three categories: strong relationships and a comprehensive treatment programme; engaged, knowledgeable staff who lead with warmth; and self-development through new experiences.

Strong Relationships and a Comprehensive Treatment Program

Participants perceived the structure and design of the treatment programme positively. They appreciated its individualised approach and the inclusion of numerous group sessions and were satisfied with the combination of lectures, individual therapy sessions, group discussions, mindfulness exercises and physical activities, such as yoga and tai chi.

Several participants expressed joy over the sense of community that had formed within the treatment groups and mentioned that they had gained lifelong friends. They also desired more activities together, such as tai chi, both during treatment and in their free time.

Most of the participants expressed deep gratitude for the opportunity to undergo the programme. Some even indicated their willingness to recommend the programme to others and expressed a desire to participate again if given the chance. The programme had played a significant role in enhancing participants’ quality of life.

Engaged, Knowledgeable Staff Who Lead with Warmth and Security

A recurring theme mentioned by many clients was their sense of security, which resulted from their satisfaction with the staff and their efforts. Important characteristics of the staff were described, such as openness, warmth and expertise. These qualities instilled a sense of security and stability, particularly in group settings, in which some clients stated that they would typically feel insecure. The staff’s professional and warm approach, commitment and support made clients feel heard and seen, thereby strengthening their trust in the staff.

Self-Development through New Experiences

The results indicated that clients experienced gaining new experiences, an improved self-image and greater insight into how to address their issues and their own illness. Many also reported that the treatment provided new opportunities for changing a destructive lifestyle and instilled hope for a better future.

The opportunity for self-reflection on their situation was perceived positively by several clients. Additionally, many acknowledged feeling as though they had been given a fresh start in life and that, thanks to the programme, they were able to see things from a new perspective.

The results showed that clients who underwent this integrated intensive outpatient treatment rated it highly, expressing high satisfaction with both the treatment programme and the efforts of the staff, as well as with the transformative processes that occurred.

In the category of strong relationships and a comprehensive treatment programme, clients described their satisfaction with the integrated intensive treatment, which included psychoeducation, group intervention, group sessions, individual therapy sessions, yoga, mindfulness, tai chi and acupuncture. The use of complementary methods is increasing internationally [16]. However, it is difficult to determine the exact frequency of their use in addiction care in Sweden. While several studies [e.g.17,18]. have suggested that the side effects of complementary methods are nearly non-existent, Olsson et al. [16], highlight the risk that the use of complementary methods may overshadow conventional care. Nevertheless, the use of complementary medicine and treatment is regulated by patient legislation [19], to ensure that such methods do not negatively affect primary treatment. The results demonstrated that integrated intensive addiction outpatient care enhances individuals’ self-perception and quality of life. Körkel [20] suggested that individuals with substance use disorders often lack the motivation to break free from addiction for life, primarily due to a poor self-image resulting from past unsuccessful attempts. The challenge with non-sustained motivation is akin to the goal of relapse prevention, which aims to bring about change. To increase individuals’ quality of life and strengthen their self-image, it is necessary for staff to have knowledge of the underlying factors contributing to their substance misuse [20]. Regarding the improved self-image and enhanced quality of life reported by the study participants, the results also revealed that the participants perceived group sessions as contributing to establishing connections and relationships with each other. The significance of the group dynamic can greatly impact the treatment process, particularly in fostering a sense of belonging and participation.

The study results also showed that clients experienced group sessions as contributing to building connections and relationships among them. The significance of the group can have a great impact during treatment, including fostering a sense of community and participation. Group therapy is a common recurring theme in addiction treatment, according to the Substance Abuse and Mental Health Services Administration [21]. The group becomes a forum for members to share their stories and perspectives and engage in discussions. Clients’ relationships with each other within a group are equally as important as their relationships with staff. Self-stigmatisation among individuals with substance use disorders often leads to low self-esteem, shame and a tendency to avoid seeking help. The group becomes a place where participants can find support from someone they can relate to, as suggested by Ripley and Welfare [21]. Being included in a group can help break the loneliness that many individuals may feel. Although the clients in this study praised their groups, it is important to note that group sessions can also create discomfort for some individuals. There can be a fear of being confronted and judged by the group, especially in relation to relapse [21]. A group in which members feel uncomfortable hardly has the same positive effect as a group in which everyone feels secure; hence, the individuals’ words about the group experience carry weight. This can be related to the responses to the quantitative questions, in which the answers indicated that the majority of clients were very satisfied with their experiences at the treatment facility. They also expressed a high level of assimilating information, indicating overall satisfaction.

In the category of committed, knowledgeable staff who lead with warmth, the clients highlighted the significant role of the staff and their person-centred approach. Kermode [22] previously emphasised the importance of staff considering each person’s strengths, desires and goals instead of viewing participants as a homogeneous group of ‘substance users’. The results described how the staff played a significant role in creating positive experiences for the clients. Thanks to the warm approach, engagement and support of the staff, the clients felt seen and heard. The staff’s contribution to the positive experience can be linked to person-centred care [23]. The strong relationship between clients and staff was mentioned several times in the clients’ evaluations. It was evident that the staff’s warmth and openness conveyed a sense of security and stability, allowing clients who may have felt uneasy in group settings to relax. The motivation to complete the treatment programme was greatly influenced by the alliance built between clients and staff. To find meaning during treatment, it is important for individuals to feel comfortable with staff and accepted for who they are. Previous research supports the significance of the therapeutic relationship [24], highlighting that a therapeutic relationship depends on vulnerabilities from both sides. The client’s vulnerability lies in their need for help from the staff, while the staff’s vulnerability lies in their caregiving role. Both share the ambition of becoming someone they want to be, although they have not yet achieved this. Thus, vulnerability is the mutual core of the therapeutic relationship’s success [24]. Furthermore, they expressed gratitude for the opportunity to be part of integrated intensive addiction outpatient care. Many also felt that the knowledge they acquired contributed to an improved self-image and the ability to develop new coping strategies through treatment. Psychiatric issues coexisting with substance use disorders make recovery more challenging, involving complex needs and situations [22]. Therefore, healthcare services need to adapt to meet these needs. Often, only the primary diagnosis is prioritised, while other coexisting conditions/illnesses tend to be overlooked. Körkel [20] argued that staff attitudes towards an individual and their goals play a crucial role in motivating change. This aligns with person-centred care, which emphasises the importance of the individual’s own desires as a motivating factor [25].

The study highlights the significant benefits of integrated intensive outpatient programs for individuals with substance use disorders. The findings revealed high levels of client satisfaction, emphasising the importance of strong relationships and comprehensive treatment programs, the role of engaged and knowledgeable staff and the value of self-development through new experiences. Despite these positive outcomes, this study underscores the need for further research on, knowledge about and competence in integrated treatment interventions for individuals with substance use disorders and comorbid mental health conditions. This continued exploration is crucial for enhancing the effectiveness and accessibility of comprehensive care for this population.

Strengths and Limitations

A limitation of this study was the modest size of the study population, due to a high dropout rate, which affects the generalisability of the results. However, a high dropout rate is common in clinical research concerning patients in SUD-specific programs/interventions [e.g. 26,27]. A strength, and at the same time, a limitation of the study was that the clinic in question is one of a few—possibly the only—clinics that provide the studied form of addiction treatment in Sweden, which limited the potential number of participants. This is the first study in Sweden that described the clients’ own experiences of CBT-based integrated intensive addiction care treatment.

Acknowledgements

We would like to express our gratitude to all the participants who took the time to respond to the online questionnaire.

Authors’ Contributions

C.J: Formal analysis, Supervision, Writing -review and editing. I.A: Formal analysis, Writing- original draft. M.N: Formal analysis, Writing-original draft. K.B: Data Curation, Writing-review and editing. NK: Conceptualization, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review and editing.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of data and materials

The data that support the findings of this study are available from KB, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of KB.

Ethical approval and consent to participate

The clinical data analysis was approved by the Swedish Ethical Review Authority (reference no. 2022-04639-01), and so, it adheres to the guidelines of the Declaration of Helsinki [28]. The data collection included informed consent. The participants were provided with clear information about the purpose of the data collection and what their participation would entail.

Consent for publication

All authors have read and approved the final manuscript. We confirm that we have obtained consent from all participants involved in the study and that all authors consent to the publication of this manuscript in the journal Addiction Science & Clinical Practice.

Conflict of Interest

KB is the director of the addiction outpatient clinic. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

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No competing interests reported.

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Clients’ Experiences and Satisfaction with an Integrated Intensive Outpatient Program for Substance Use Disorders

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Version 1

Abstract

Figures

Highlights

Introduction

Treatment of Substance Use Disorders: Psychological and Psychosocial Interventions

Methods

Study Design and Procedure

Context

Participants

Data Collection

Data Analysis

Results

Qualitative Content Analysis

Strong Relationships and a Comprehensive Treatment Program

Engaged, Knowledgeable Staff Who Lead with Warmth and Security

Self-Development through New Experiences

Discussion

Conclusion

Strengths and Limitations

Declarations

References

Additional Declarations

Status:

Version 1