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Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 RESEARCH ARTICLE Open Access Improving psychosocial health and employment outcomes for individuals receiving methadone treatment: a realist synthesis of what makes interventions work Lois A Jackson1,2*, Jane A Buxton3, Julie Dingwell4, Margaret Dykeman5, Jacqueline Gahagan1,2, Karen Gallant1, Jeff Karabanow6, Susan Kirkland7, Dolores LeVangie1,2, Ingrid Sketris8, Michael Gossop9 and Carolyn Davison10 Abstract Background: For over 50 years, methadone has been prescribed to opioid-dependent individuals as a pharmacological approach for alleviating the symptoms of opioid withdrawal. However, individuals prescribed methadone sometimes require additional interventions (e.g., counseling) to further improve their health. This study undertook a realist synthesis of evaluations of interventions aimed at improving the psychosocial and employment outcomes of individuals on methadone treatment, to determine what interventions work (or not) and why. Methods: The realist synthesis method was utilized because it uncovers the processes (or mechanisms) that lead to particular outcomes, and the contexts within which this occurs. A comprehensive search process resulted in 31 articles for review. Data were extracted from the articles, and placed in four templates to assist with analysis. Data analysis was an iterative process and involved comparing and contrasting data within and across each template, and cross checking with original articles to determine key patterns in the data. Results: For individuals on methadone, engagement with an intervention appears to be important for improved psychosocial and/or employment outcomes. The engagement process involves attendance at interventions as well as an investment in what is offered. Three intervention contexts (often in some combination) support the engagement process: a) client-centered contexts (or those where clients’ psychosocial and/or employment needs/issues/skills are recognized and/or addressed); b) contexts which address clients’ socio-economic conditions and needs; and, c) contexts where there are positive client-counselor and/or peer relationships. There is some evidence that sometimes ongoing engagement is necessary to maintain positive outcomes. There is also some evidence that complete abstinence from drugs (e.g., cocaine, heroin) is not necessary for engagement. Conclusions: It is important to consider how the contexts of interventions might elicit and/or support clients’ engagement. Further research is needed to explore how an individual’s background (e.g., involvement with different interventions over an extended period) may influence engagement. Long-term engagement may be necessary to sustain some positive outcomes although how long is unclear and requires further research. Engagement can occur without complete abstinence from such drugs as cocaine or heroin, but additional research is required as engagement may be influenced by the extent and type of drug use. Keywords: Methadone treatment, Engagement, Realist synthesis, Opioids, Opiates, Employment outcomes, Psychosocial health, Client-centered, Socio-economic conditions, Positive relationships * Correspondence: Lois.Jackson@dal.ca 1 School of Health and Human Performance, Dalhousie University, 6230 South Street, P.O. Box 15000, Halifax, NS B3H 4R2, Canada 2 Atlantic Health Promotion Research Centre, Dalhousie University, 1318 Robie Street, Halifax, NS B3H 3E2, Canada Full list of author information is available at the end of the article © 2014 Jackson et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 Background For over 50 years methadone has been prescribed to opioid-dependent individuals as a pharmacological treatment for opioid dependence (Grönbladh and Öhlund 2010; Fischer 2000) as it reduces the symptoms of opioid withdrawal and opioid cravings (King et al. 2002; Prince Edward Island Department of Health 2008; Reist 2010). Opioid dependence is more than a heavy use of opioids; it is a chronic pattern of use with complex physiological, psychological and social impacts that affect individual users, their families and communities (Berkman and Wechsberg 2007; WHO, UNODC, UNAIDS 2004; Prince Edward Island Department of Health 2008; Reist 2010). The efficacy of methadone is well established when taken at the recommended dosage, and long-term maintenance treatment has been associated with such outcomes as reduced use of opioids and reduced criminal activity (Reist 2010; Ward et al. 1994; Gossop 2006; Gossop et al. 2001; SACDM Methadone Project Group 2007). Although methadone is a well-established pharmacological treatment, individuals often require additional social interventions such as counseling services or other support services, to help improve their health and quality of life (Abbott et al. 1999; Berkman and Wechsberg 2007). Various social interventions targeting individuals on methadone have been implemented in different places. However, at the time of this study, and to the best of our knowledge, there were no systematic reviews of evaluations of social interventions specifically aimed at improving the psychosocial health and employment outcomes of individuals on methadone. Our research was aimed at filling this gap because of the importance of psychosocial health and employment to individuals’ health and quality of life. The research team was composed of community workers providing services to people on methadone (e.g., individuals working in an AIDS [Acquired Immunodeficiency Syndrome] organization or needle exchange program), policy-makers in the area of substance use, and academic researchers from various disciplines (e.g., health promotion, social work, pharmacy, psychology, epidemiology). The expertise of team members spanned the areas of harm reduction, substance use, and the health of marginalized populations. Originally, our research question focused on evaluations of interventions aimed at methadone retention and/or improving the physical, social, and mental/emotional health outcomes of individuals on methadone. However, as we conducted our search of evaluations it became clear that we needed to refine our review given the number of evaluations. It also became clear that a number of evaluations included employment outcomes as a marker of improved health or quality of life. Therefore, we focused on evaluations of interventions aimed at improving the psychosocial (e.g., self-esteem, positive social Page 2 of 20 networks) and/or employment (e.g., hours of paid labour) outcomes of individuals on methadone. The key question was: What formal interventions work (or not) for individuals on methadone to improve their psychosocial health and/or employment outcomes? The term formal interventions was defined as interventions that are formally planned and implemented (and usually funded) as opposed to informal interventions such as those developed and implemented by family members. We focused on evaluations from 1980 to 2011. Articles from 1980 on were included because this is when “there was growing demand for treatment and mounting evidence of the merits of methadone treatment” (Reist 2010, p. 2). The search process began in December 2011. Methods Rationale for using the realist synthesis The realist synthesis method was utilized because, unlike a meta-analysis, the realist approach goes beyond an assessment of what works and seeks to understand why social interventions work (or not) (Wong et al. 2011; Wong et al. 2012). Understanding why social interventions work is critical to help guide policy makers and practitioners in determining the contexts and resources needed “to most likely…produce the desired outcome” (Wong et al. 2013). The realist approach accepts that social interventions are complex and messy given that they consist of “multiple human components (teachers, learners, etc.) that interact in a non-linear fashion to produce outcomes which are highly context dependent” (Wong et al. 2010). A key aim of a realist synthesis is to explain why interventions lead to certain outcomes in some contexts and not others, and why they might work for some subpopulations and not others (Pawson et al. 2005). The realist synthesis “adopts a theory-driven approach to evidence synthesis, underpinned by a realist philosophy of science and causality” (Rycroft-Malone et al. 2014, p. 3). As Rycroft-Malone et al. (2014) explain, Causal explanations are expressed as contingent relationships between mechanisms (changes in participants’ reasoning or resources), context (contingencies) and outcomes, often abbreviated to context-mechanism-outcome configuration (CMO) to show how particular contexts or conditions trigger or fire mechanisms to generate an observed outcome. (p. 3) The realist approach does not provide a definitive answer about what works, but does provide detailed information about the contexts and mechanisms which explain how, for whom, and in what circumstances the interventions work (or not) (Pawson 2006). Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 An underlying assumption of a realist review is that all social interventions are based on a theory or theories about how to change behaviours (Pawson 2006, p. 74). Architects of interventions believe that if an intervention is delivered in a certain way it will produce particular results. The underlying theory(ies) is/are not always made explicit; however, a key task of a realist synthesis is to articulate the underlying theory or theories, and “interrogate the existing [empirical] evidence to find out whether and where these theories are pertinent and productive” (Pawson 2006, p. 74). Within a realist synthesis, each study is examined for what it can add to the theoretical understanding of how and why interventions work (or not), and studies are included from varied sources including the grey literature (e.g., non peer-reviewed government reports). Consistency in methods and outcome measures across primary studies and evaluations is not a requirement (Jackson et al. 2009; O’Campo et al. 2009; Walshe and Luker 2010). Indeed, studies are often quite varied in terms of study design, length of implementation and follow-up, as well as specific outcomes. Figure 1 Initial search process. Page 3 of 20 The search process As noted above, our original question focused on formal interventions seeking to maintain individuals on methadone and/or improve their physical, social and mental health. A Clinical Librarian (KN) assisted with the development of the search strategy to obtain articles on evaluations of these types of interventions. See Additional file 1 for our initial search strategy and terms. Based on our original search strategy (including searching reference lists of flagged articles or citation pearling), 1514 citations were found (Figure 1. Initial search process). Of these, 804 were deemed not applicable (according to the title and abstract), and 710 met our inclusion criteria based on our original research question. At this time, through discussions with the research team, there was consensus that the research question was too broad as it covered not only a vast literature on methadone retention, but also health outcomes for those on methadone. Therefore, the research question was narrowed to evaluations focused on health outcomes (defined in terms of physical, social or mental/emotional health), and articles centered on methadone retention were Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 Page 4 of 20 excluded because the research team prioritized health outcomes as of current importance in informing program and policy decisions. With the change in the research question, 108 articles met our new inclusion criteria of health outcomes (physical, social, mental/emotional health). These 108 articles were reviewed in more depth. Forty-seven articles were excluded because they did not meet the inclusion criteria, and thus 61 articles remained. As the 61 articles were reviewed there was consensus once again to limit the scope of the synthesis given the available time and resources. It was agreed that in order to do this we should focus on one or more specific health outcomes (e.g., physical, social and/or mental/ emotional health). To facilitate this process the primary health outcome for each article was assessed, and the articles sorted according to the key health outcome. As we began to do this, however, it became clear that the articles did not fall clearly into the three categories of physical, social and/or mental/emotional health outcomes. There were some articles that reported on “overall health” so these were sorted into one group. Some articles focused on what we viewed as physical health outcomes (e.g., smoking cessation) and were placed into a ADDITONAL SEARCH #1 Formal interventions focused on psychosocial outcomes that were conducted outside of the US.* 199 records identified through database searching, with duplicates removed (PubMed, EMBASE andEBSCOhost). Sept. – Oct. 2012 195 articles excluded based on title/ abstract 4 articles read in full assessed for eligibility 4 articles excluded 0 articles eligible * Since all but 1 evaluation were US based, we wanted to ensure none from outside of the US were missed. Figure 2 Additional search process. second group. Other articles focused specifically on reducing high risk behaviors (e.g., reduced needle sharing) so were placed in a third grouping. A number of articles reported on psychosocial outcomes (e.g., improved selfesteem, involvement in non-drug using networks) so these were placed into a fourth grouping. Finally, a number of the articles centered on employment outcomes (e.g., hours of paid work) so these were placed into a fifth grouping. At this point in time, there was consensus that the synthesis would center on interventions where the key outcomes were psychosocial and/or employment outcomes. Articles with these two types of outcomes were chosen because of the importance of psychosocial health and employment to individuals’ quality of life. At this point in time, 26 of the 61 articles centered on psychosocial and/or employment outcomes. With this revised inclusion criteria some previously excluded articles were re-evaluated, and two were added to the synthesis, totaling 28. Additional searches were conducted to ensure we were capturing all relevant articles. Through these added searches, as well as citation pearling, three additional articles were found (Figure 2. Additional search process). Therefore, the total number of articles in our ADDITIONAL SEARCH #2 Formal interventions focused on psychosocial and employment outcomes 163 records identified through database searching, with duplicates removed (PubMed, EMBASE, CINAHL,SocINDEX, Social Work Abstracts, PsycINFO and Web of Knowledge) and one through citation pearling. Nov. 2012 161 articles excluded based on title/ abstract (some already in template) ADDITIONAL SEARCH #3 Formal interventions focused on psychosocial and employment outcomes 121 records identified through database searching, with duplicates removed (PsychInfo, Pub Med). July – Aug. 2013 1 article added from citation pearling 21 articles read in full, assessed for eligibility 2 articles read in full assessed for eligibility 18 articles excluded 2 articles excluded 0 articles eligible 101 articles excluded based on title/abstract (some already in template) 3 articles added to synthesis Total: 28 (Initial search) + 3 (Additional searches) = 31 Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 synthesis is 31. As the synthesis progressed we also sought literature to assist us in understanding our developing theory of why interventions for individuals on methadone appear to work or not. Inclusion and exclusion criteria Studies were included in the synthesis if they were quantitative and/or qualitative evaluations, peer reviewed, published from 1980–2011, and written in English. As Pawson and colleagues note (2005, p. S1:30), judgements concerning rigor are made based on whether the study can make “a methodologically credible contribution to the test of a particular intervention theory” and the 31 studies were deemed to contain sufficient data to contribute to testing the theory about why the interventions work (or not). Studies were excluded if: (a) they focused on family therapy or parenting outcomes or outcomes related to family members or others not on methadone treatment; (b) they included individuals on methadone as well as others not on methadone, but the outcomes for individuals on methadone were not clearly indicated; (c) there were no clear psychosocial and/or employment outcomes or the evaluation was mainly centered on drug use outcomes; and (d) the intervention was described as a methadone maintenance treatment (MMT) program with no clear indication of the component or components beyond methadone substitution that may have contributed to the psychosocial and/or employment outcomes. Many of the articles specifically listed their outcomes as psychosocial or employment, but in some cases the outcomes were apparently psychosocial yet not explicitly stated as psychosocial. In these cases, we assessed the reported outcome(s) based on how psychosocial was defined in other articles (e.g., reduced depression, involvement with nondrug activities), as well as our assessment of the fit of the outcomes within this category. In cases where there was disagreement between the Research Co-ordinator (MMD) and Principal Investigator (LJ), at least two other members of the research team assessed the articles to determine the fit with the criteria. Some of the 31 interventions had objectives beyond improving psychosocial and/or employment outcomes, such as reduced drug use or retention in the program. These other outcomes are discussed only insofar as they are relevant to understanding the psychosocial and/ or employment outcomes. Data extraction In consultation with the research team, four templates were created to extract and organize the data and assist with data analysis. The first template, (organizational template), numbered each article, and provided an overview of the article including the citation, objective of the study, summary of the intervention(s), study population and, overall results. The second template, (mechanisms template) was used to Page 5 of 20 help capture data on what appeared to be the causal connectors (implicit or explicit) between the intervention and outcomes or what appeared to cause the intervention to work (or not work) (e.g., clients actively taking part in the activities). The third template, (context template), documented contextual factors (e.g., positive relationships between counselors and clients) that appear to be important to sparking the mechanism, and the fourth template (outcomes template) provided information on key outcomes of the intervention. We developed the templates in terms of contexts, mechanisms and outcomes because within a realist review explaining behaviour patterns is done “by critically scrutinising the interaction between context, mechanism and outcome in a sample of primary studies” (Wong et al. 2010). Certain contexts may spark or elicit mechanisms, and thus generate “outcomes of interest” while others may not (Wong et al. 2012, p. 91). This means that, “An intervention itself does not directly change its participants; it is the participants’ reaction to the opportunities provided by the programme that triggers the change” (Wong et al. 2012, p. 92). Reading the articles and developing the templates was an ongoing iterative process. As the Research Co-ordinator (MMD) and Principal Investigator (LJ) read the articles; the templates were revised following discussion and critical reflection with the research team. As our understanding of the articles developed we further refined the information in the templates. Through this process of constant comparison between the templates (often returning to the original articles to ensure that information in the templates had not been taken out of context), common themes or patterns were identified. The evolving patterns were discussed with all of the team members at a face-to-face workshop (November 2012). The themes were revised in light of the discussion, and after a re-examination of the templates as well as the original articles. Further refinement of the patterns in the data continued with the authors of the paper until agreement was reached. Following an assessment of the key patterns, two members of the research team (DL and LJ) reviewed once again the articles, and checked the fit of the patterns with the articles. We also attempted to identify disconfirming data or data that might challenge or refute our candidate theory. It is important to note that in this study a key focus is on the contextual factors that elicit or spark the mechanism that is linked to positive intervention outcomes. Contextual factors are the focus because one key over-riding mechanism was found to be linked to positive intervention outcomes. Results An overview of the interventions An underlying assumption found in the 31 evaluations is that individuals on methadone treatment have a deficit Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 or problem in how they think and/or behave that needs to be changed. There was great variability among the articles in terms of the specific problem(s) targeted for change, with some focusing on several different problems or issues. In some cases, the problem was not explicitly identified but was implicit in the evaluation. Overall, however, the interventions targeted a variety of cognitive/emotional problems (e.g., problem solving, self-esteem), and/or different behaviours (e.g., social involvement) (See Table 1 for some examples). In a number of instances, the goal was for the individual to achieve abstinence from drugs (other than methadone), or reduce drug use/alcohol use, in conjunction with other changes. At times, an underlying assumption was that continued drug use (e.g., cocaine use) interferes with the ability to improve psychosocial and/or employment outcomes. The majority of the interventions included individual/ group counseling or therapy as a component of the intervention. However, various approaches were utilized (and varied combinations) such as cognitive behavioural therapy (Aszalos et al. 1999), supportive decision-making (Bigelow et al. 1980), and mapping or visually representing feelings and actions (Joe et al. 1994). A number of interventions had, in addition to a therapy or counseling component, other components such as an educational element, or referral to services (e.g., legal services). Various outcome measures were used to assess changes (See Table 2 for some examples). Many of the evaluations reported positive outcomes, a few reported no improvement, and in some instances, there was a mix of outcomes often depending on the outcome measure or group (e.g., control group versus experimental group). The evaluations also varied in terms of the groups targeted for the intervention or the inclusion and exclusion criteria. For example, some interventions targeted men only (McLellan et al. 1993), male veterans (Woody et al. Page 6 of 20 1987), or women only (Najavits et al. 2007). In one study, individuals were “ineligible if they were dependent on alcohol or benzodiazepines to the point of requiring medical withdrawal” (Farabee et al. 2002, p. 344) or eligible if dependent on alcohol (Cohen et al. 1982). There were also differences in how long clients had to have been on methadone to be eligible for the intervention. For example, individuals on methadone for at least 6 months (Nurco et al. 1995), or on methadone for a minimum of 90 days (Farabee et al. 2002). In spite of the variability in the specific populations targeted, most interventions included individuals who were of low socio-economic status as indicated by education, low or under employment, housing status, and/ or living on social security benefits (Coviello et al. 2009; Aszalos et al. 1999; Coviello et al. 2004; Farabee et al. 2002; Nurco et al. 1995; Ronel et al. 2011). In addition, many had been drug-involved for a number of years (Glickman et al. 2006; Nurco et al. 1995; Ronel et al. 2011). This suggests that the results of this synthesis apply mainly to populations of low socio-economic status with a significant history of drug use (i.e., individuals who have used drugs such as cocaine and heroin for a long period of time). Candidate theory In the early stages of the analysis a key pattern was evident in the data: attendance at the intervention (or what some articles refer to as retention or compliance) was associated with positive client outcomes, and conversely, lack of attendance was linked to poor outcomes. However, good attendance was also sometimes linked to disappointing outcomes suggesting that attendance alone does not lead to positive outcomes. Our candidate theory, therefore, was that attendance at interventions was important but not enough for positive outcomes. Lidz et al. (2004) argued, based on the evaluation of an intervention with disappointing outcomes, Table 1 Some examples of changes targeted by the various interventions Cognitive/emotional changes Behavioural changes • Problem solving skills (Abbott et al. 1998; Coviello et al. 2009; Platt et al. 1993) • Communication and drug-refusal skills (Abbott et al. 1998) • Understanding feelings and behaviors (Woody et al. 1995) • Communication between clients and counselors (Joe et al. 1994; Dansereau et al. 1996) • Self-awareness and discipline (Aszalos et al. 1999) • Communication skills (Joe et al. 1997) • Attention problems (Joe et al. 1994) • Change in activities, such as avoiding drug-using friends (Farabee et al. 2002) • Depression (Carpenter et al. 2006) • Greater understanding of self and issues related to women and drug use (implicit in evaluation) (Najavits et al. 2007) • Developing and refining interpersonal skills (e.g. problem solving and communication skills) (Nurco et al. 1995) • Communication and reasoning processes (Joe et al. 1997) • Leadership skills (Glickman et al. 2006) • Motivation to employment (Coviello et al. 2004) • Job acquisition (Kidorf et al. 1998) • Productive activity (Cohen et al. 1982) • Action steps to employment (Coviello et al. 2004) Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 Page 7 of 20 Table 2 Some examples of outcome measures from the interventions Psychosocial outcomes Employment outcomes • Enrollment in health care coverage, improved living conditions (Aszalos et al. 1999) • Employment status (mean hours employed per week) (Bigelow et al. 1980) • Helping others (i.e., leadership) (Glickman et al. 2006) • Days employed (Cohen et al. 1982) • Drug avoidance activities (Farabee et al. 2002) • Obtained employment (Magura et al. 2007) • Reduced impulsive-addictive behaviour (Najavits et al. 2007) • Perceived motivation to obtain a job (Coviello et al. 2004) • Increased rapport self-confidence, and motivation (Dansereau et al. 1996) • Behavioural actions to obtain a job (e.g., completing job applications) (Coviello et al. 2004) • Productive activity (which included number of arrests) (Cohen et al. 1982) • Job acquisition (having worked at least one day in the 30 days prior); mean monthly income (Coviello et al. 2009) • Increased internal locus of control (Nurco et al. 1995) • Number of vocational-educational services (e.g., pre- employment workshops) involved with (Appel et al. 2000) • Improvement in psychiatric symptoms (Woody et al. 1987) • Number of days employed in past 30 days (McLellan et al. 1993; Zanis et al. 2001) • Counselor ratings of rapport, motivation and self-confidence (Joe et al. 1994) that in order to be successful, interventions need to, “engage patients, and command their attendance and active participation” (p. 2302). We began, therefore, to look at the literature on engagement, and more specifically literature focused on drug treatment and engagement. As we explored this literature we found that a number of researchers suggest that engagement is linked to positive outcomes. Fiorentine et al. (1999) argue that there is evidence that “client engagement in [drug] treatment is significantly associated with positive treatment outcomes” (p. 199). Likewise, Broome et al. (2007) maintain that, “the engagement or active participation of clients in [drug abuse] treatment is a critical step leading to better outcomes” (p. 149). As we examined this literature in more depth, it became clear that there is no single definition of engagement (sometimes referred to as involvement), and it has been operationalized in different ways. As Broome et al. (2007) note, “Client engagement has been operationalized as session attendance or through a broader set of personal reactions, including building rapport or therapeutic alliance with a counselor, openness and participation within sessions, and perceived general helpfulness of or satisfaction within treatment” (p. 149). Speaking about clients’ engagement with therapy, Hill (2005) contends that, “client involvement refers to the degree of client engagement in the session, or the extent to which the client becomes immersed in the tasks required of the particular therapy” (p. 433). According to Hill, “client involvement might be inferred if the client initiates topics, explores the presenting problem, struggles to gain insight, participates in behavioral change activities, or openly informs the therapist about reactions or complaints” (2005, p. 433). Tetley et al. (2011) further argue that, “engagement refers to the extent to which the client actively participates in the treatment on offer” (p. 927). They maintain that: To participate in therapy, clients must consistently attend the arranged therapy sessions and complete the specified course of treatment. In addition to this, clients must also be willing to share their inner world by disclosing their thoughts, feelings, problems, and history. Engaging in between-session tasks is also a requirement of clients in therapy. This includes thinking things over, trying out skills and doing homework. (Tetley et al. 2011, p. 928) Key contexts within which interventions work (or not) Based on this client engagement in drug treatment literature, and our initial review of the articles and templates, we hypothesized that engagement is the key mechanism through which change happens and that it involves both attendance at sessions as well as various personal reactions such as active participation in what is offered, openness to sharing thoughts, feelings, etc. We examined each template, and in turn the corresponding article, to determine the fit with this initial candidate theory. Through this process, we found that engagement appears to occur in some contexts and not in others. Specifically, we found three key contexts: (a) a client-centered context, and more specifically a context where clients are supported in articulating/ addressing the psychosocial/employment needs/issues/ skills that are important to them; (b) a context where the challenges of clients’ socio-economic lives are recognized and/or there are attempts to provide socio-economic assistance; and (c) a context in which there are quality/positive relationships between counselors and clients and/or among clients. Contexts (b) and (c) are frequently found together with context (a) or a client-centered context. Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 Our synthesis further found that ongoing engagement may, in some instances, be necessary for continued psychosocial and/or employment changes although the evidence for this is not strong. In addition, based on our analysis it appears that engagement can occur even when clients are not abstinent from drugs (e.g., there is some continued use of cocaine, heroin). However, it is unclear whether or not there is a ceiling over which drug use interferes with engagement, and/or if the type of drug might affect engagement. We present below some key examples of the findings. 1) Intervention contexts that elicit and/or support engagement a) Client-centered contexts Intervention contexts where clients are supported in articulating/addressing the psychosocial/employment needs/ issues/skills important to them, appear to elicit and/or support engagement. This process is often (although not always) linked to positive psychosocial and/or employment outcomes. Client-centered contexts or those where clients are supported in articulating and/or addressing psychosocial/ employment needs/issues/skills of value to them, appear to be important for engagement and thus positive outcomes (Additional file 2, see Contexts 1a). For example, one qualitative evaluation reported some positive results for an intervention that used a twelve-step program adapted to methadone clients in which clients were encouraged to articulate their issues in an accepting and supportive atmosphere where “members could feel comfortable and uninhibited to share their difficulties” (Ronel et al. 2011, p. 1142). The researchers argue that there were some positive changes because, “as the group progressed, there were meaningful social interactions between members during and in between meetings that possibly represented meaningful group processes” (Ronel et al. 2011, p. 1147). The researchers further argue that some “members who were formerly isolated established new friendships within the community of the group” (p. 1147). Nurco et al. (1995) likewise reported some positive results in their evaluation, and in this intervention the experimental group “demonstrated statistically significant changes in locus-ofcontrol beliefs, from external to internal causation, about personal responsibility for drug misuse” (p. 765). The intervention was a clinically-guided self-help group (CGSH) that not only involved social and recreation activities (e.g., going to the movies) but discussions of “issues of self-declared importance” suggesting support for clients to articulate their issues (Nurco et al. 1995, p. 769). Platt et al. (1993) reported positive outcomes for an employment intervention where participants were “helped in clarifying their own attractions and barriers to work”, and the barriers were used “as the basis for specifying individualized Page 8 of 20 objectives and plans for action” (p. 23). The individualized approach points to a client-centered context, and the types of activities that supported clients in articulating their own employment barriers included exercises, group discussions, brainstorming, case studies as well as role playing. According to the researchers, “this study demonstrated a significant increase in employment” six months following the intervention, and jobs were not created or assigned to clients but rather, they had to “search out, apply for, and be hired for a position on their own” (Platt et al. 1993, p. 27). A manual-based intervention targeting women which involved readings and exercises from a workbook, focused on “themes and psychoeducation relevant to women” pointing to a client-centered context (Najavits et al. 2007, p. 6). Not only was there a high attendance rate (87% of available sessions) but clients reported strong treatment satisfaction suggesting engagement with the intervention. According to the researchers, “Results indicated significant improvements from intake to 2 months later on key variables most related to treatment:…impulsive-addictive behaviour, global improvement and knowledge of the workbook concepts” (Najavits et al. 2007, p. 9). Other variables (e.g., employment, psychological problems) “despite being non-significant over time, were largely in the direction of improvement” (p. 8–9). In an intervention evaluated by Coviello et al. (2009), the experimental group received treatment based on interpersonal cognitive problem solving (ICPS) focused on drug and employment counseling. The control group also received treatment based on ICPS but only focused on drug counseling. Both groups had improved employment outcomes and it appears that this was because in both groups there was support for clients to think through “his/her own problems and select a range of implementable options that could potentially be helpful in reaching a realistic goal” (Coviello et al. 2009, p. 190). Indeed, the authors argue that one of the reasons why there was no significant treatment effect between groups is likely because “both groups received the problem-solving intervention, [and] the control group could have generalized these strategies to finding work” (p. 195). Node-link mapping which requires clients’ to map their issues through the drawing of a physical map (often in conjunction with the counselor), was evaluated in three articles (Joe et al. 1994; Joe et al. 1997; Dansereau et al. 1996). According to Dansereau et al. (1996), visual maps are used to “represent interrelationships comprising personal issues and related plans, alternatives or solutions visually” (p. 364). In two evaluations (Dansereau et al. 1996; Joe et al. 1994), clients in the mapping groups improved on psychosocial measures (i.e., counselors’ rating of clients on rapport, motivation and self-confidence). It appears that the improvement in the mapping groups was Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 related, at least in part, to the support (through mapping) in helping clients to articulate their issues. The third evaluation reported mixed results depending on the outcome measure (Joe et al. 1997). The researchers suggest that the negative outcomes may be because the mapping allowed “clients to see their psychological and social strengths and weaknesses in a more critical (and perhaps more realistic) light” (Joe et al. 1997, Discussion para 3), and this suggests that in some cases, articulating one’s issues may be overwhelming and may lead to negative outcomes, at least for a period of time. A number of studies that supported clients in developing needed skills also reported positive outcomes. For example, a mandatory employment program based on behavioural contingencies (e.g., more intensive counseling if clients did not meet the employment goals) was evaluated by Kidorf et al. (1998), and found that most clients (75%) secured employment and maintained the position for at least one month. In this intervention, the counselors helped clients with a number of employmentrelated issues (e.g., strategies for seeking employment) as well as help in “completing applications, creating resumes, and identifying job and volunteer openings,” indicating a client-centered context (Kidorf et al. 1998, p. 78). Zanis and Coviello (2001) evaluated an employment case management intervention involving 10 clients, and the intervention also appeared to support engagement through a client-centered approach of assisting with skill development. The researchers argue that the intervention was, “designed to motivate chronically unemployed persons to engage in work, assist in job placement, and provide post employment support through workforce integration, while maintaining progress in drug treatment” (Zanis and Coviello 2001, p. 67). Part of the intervention included teaching relevant life skills, such as “how to use public transportation, budget money, decide on a health insurance plan, how to request a day off from work, how to communicate with employers, etc.” (p. 69). According to the researchers, “Nine of the 10 clients were employed at the two-month follow-up assessment and six maintained employment at the eight-month follow-up. Moreover, three clients were able to successfully transition from welfare to competitive private sector employment” (p. 67). Contexts that do not support psychosocial and/or employment needs/issues/skills of importance to clients do not appear to support engagement and are linked to no change or poor outcomes. In a couple of evaluations there was little, if any, change reported. Although it was not always clear why this was the case, it appears that in some instances it was because the clients were not fully engaged with the intervention. Lack of engagement appears to have been because the intervention context did not support the clients in articulating/addressing a needed psychosocial and/or Page 9 of 20 employment issue (Additional file 2, see Contexts 1a [Lack of]). In two evaluations (Rounsaville et al. 1983; Cohen et al. 1982), for example, there was little or no difference between the experimental and comparison groups in outcomes, and the researchers note that there was poor attendance in the interventions. Rounsaville et al. (1983) compared a short-term interpersonal psychotherapy treatment (IPT) consisting of weekly individual psychotherapy, to a low-contact treatment consisting of one brief meeting per month. Only 38% of the IPT group completed treatment and 54% completed the low-contact condition. The researchers maintain that, “The attrition data are striking given the difficulty in attracting subjects to the study” (Rounsaville et al. 1983, p. 634). According to the researchers, most who dropped out of the IPT group “remained in the methadone program, indicating that it was the former treatment [IPT] that they failed to become engaged with and not the latter [methadone program]” (p. 634). It may be that the clients were already receiving the therapy they needed through the methadone program, and asking them to engage in more psychotherapy was not what they wanted or felt they needed. Indeed, the researchers suggest that this was the case as they note that, “there was little in our findings that would suggest that individual weekly short-term IPT provided additional benefit when added to a methadone program that already provided weekly group psychotherapy” (p. 634). Cohen et al. (1982) also note that there was very low attendance among the treatment groups in the intervention they evaluated, but that there was “considerably less resistance in their participation” in the methadone program (p.360). This also suggests that the intervention (which was centered on treating alcoholism among those deemed “operative alcoholics”) may not have been what clients wanted or felt they needed. In addition, the seminars that were part of the intervention may not have allowed the clients to be actively involved in articulating their specific issues. In another intervention the goal was to improve both psychosocial (e.g., overall personal and social adjustment) and employment (i.e., mean hours employed each week) outcomes, and although there was good attendance, there was “little average change in the treated group over the 6 months of their participation” (Bigelow et al. 1980, p. 432). The researchers note that, “counselors selected specific treatment goals, and designed and implemented treatment techniques” (Bigelow et al. 1980, p. 430). It appears, therefore, that the treatment goals may not have been those of importance to the clients. It should also be noted, however, that all participants, including the control group, received supportive counseling which may have been what all the participants wanted, and hence the high rates of participation but not a significant difference in outcomes between the groups. This supportive counseling “consisted of here-and-now based discussion of [a] client’s Jackson et al. BMC Psychology 2014, 2:26 http://www.biomedcentral.com/2050-7283/2/26 life situations, feelings, problems and alternatives, with counselors providing both suggestions and emotional support” suggesting that it was client-centered (p. 430). Finally, Lidz et al. (2004) noted disappointing outcomes from the intervention they evaluated, and argue that this was in part because the manual-based format of the intervention could not address clients’ barriers to employment such as having to explain past criminal behaviours. The researchers point out that, “Some subjects faced such complex barriers to employment that contrary to the manuals, it was often not possible to suggest realistic solutions during group discussion” (Lidz et al. 2004, p. 2303). The goal of the intervention was to improve employment rates but it appears that the context did not provide the supports and services that clients needed. As the researchers note, “…individualizing efforts to meet training needs, and providing support during job-finding and early job-holding might improve program effectiveness” (p. 2288). b) Responsiveness to clients’ socio-economic lives Intervention contexts that recognize/address the socioeconomic conditions and needs of clients, appear to support engagement, and in turn positive outcomes. In a number of interventions that were client-centered, there was also an acknowledgement of, and/or an attempt to address, clients’ socio-economic conditions and needs (Additional file 2, see Contexts 1b). For example, in some client-centered interventions socio-economic assistance was provided such as help with transportation, flexibility with bringing children to the intervention, and information on preferred shelters and accessing emergency food stamps (Aszalos et al. 1999), or help with literacy issues (McLellan et al. 1993). Although such assistance was not part of all client-centered interventions, there is some evidence that attention to clients’ socio-economic conditions and needs augments the supportive context for engagement. For example, in an intervention evaluated by McLellan et al. (1993) both the Enhanced Services (which included counseling plus on-site medical/psychiatric, employment and family therapy) and the Standard Services (counseling only) resulted in psychosocial improvements. However, the Enhanced Services had the most improvements in psychosocial outcomes over all (including employment and psychiatric status). Improvement in psychological problems and family problems among the Standard Services group might be explained by what appears to be a client-centered context such as assistance with “various problems” (McLellan et al. 1993, p. 1955). At the same time, the more positive outcomes in the Enhanced Services group might be explained, at least in part, by the fact that not only were many services offered to help address clients’ psychosocial needs, but clients were also provided with an employment counselor Page 10 of 20 who “conducted a series of workshops and group sessions designed to teach reading and prepare for a general equivalence diploma” thus helping to address their socioeconomic lives (p. 1955). Farabee et al. (2002) evaluated an intervention comparing both cognitive-behavioral therapy (CBT) and contingency management (CM), and found some positive outcomes in terms of drug-use avoidance activities, although CBT had more positive outcomes. The researchers argue that, “subjects 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” (Farabee et al. 2002, p. 348). It appears that the CBT groups were client-centered as clients were encouraged to articulate how the “topic introduced” was relevant to them (p. 346). At the same time, however, there appears to have been some engagement among the CM group as there were some positive outcomes for this group. The engagement may be attributed, in part, to the fact that vouchers were provided which could be used for subsistence items. The researchers point out that, participants were “strongly encouraged to use the voucher earnings to engage in new prosocial, non-drug-related behaviour” (p. 346), yet many wanted to use their earnings for such subsistence items as food (restaurant/fast food certificates, grocery store vouchers), or clothes for themselves or their children. Intervention contexts where clients’ socio-economic lives are not recognized do not appear to support engagement. In a couple of interventions, clients’ socio-economic lives were not recognized, and it appears that there was limited engagement (Additional file 2, see Contexts 1b [Lack of]). For example, an intervention evaluated by Lidz et al. (2004) reported disappointing outcomes, and it appears that there was limited engagement with the intervention. As the researchers note, “In some cases, subjects lacked the literacy and everyday knowledge that the manuals assumed they would have. Other subjects lacked the self-presentation skills to keep up with the pace of the programs” (Lidz et al. 2004, p. 2302). In this intervention, video feedback techniques were used “with subjects who often were not accustomed to making presentations in formal group settings” (p. 2302). The researchers indicate that the video feedback techniques embarrassed some clients when they viewed their video performances, and this made it “difficult to maintain group progress” (p. 2302). An evaluation by Coviello et al. (2004) provides an example of an employment intervention that was aimed at increasing “motivation and action step activities that lead to employment” (p. 2309), but overall there were no differences between the control group and the intervention group (p. 2310). Although the intervention appears to have been client-centered insofar as it focused on clients thinking through their problems and selecting action