Journal of Studies on Alcohol, Vol. 39, No. 7, 1978
Evaluationof a SalvationArmy Alcoholism TreatmentProgram' Rudolf H. Moos, Barbara Mehren and Bernice S. Moos SUMMARY. The functioningand participationo[ 97 men in a treatmentprogram were analyzedin what was judged to be a cost-e[[ectiveprogram [or Skid Row alcoholics.
HE SALVATION ARMY (sa) has been looking after al-
coholicsfor more than a century,and now treatswell over 50,000annuallyin the United States.The sa programsare unusualin the variety of treatmentsthey offer, includinggroup and individualtherapy,milieu therapy and participationin AlcoholicsAnonymous, and in their strongemphasison vocationaltraining and religiousand spiritualcounseling. Despite its unique scope and character,the impact of sA'streatment regimen on the rehabilitationof alcoholicshas not often been studied (1-4). There is a sizeablebody of literature on Skid Row, but most studieshave been sociological reconstructions of Skid Row society (e.g., 5, 6). Little systematicresearchdeals specificallywith the treatment
of Skid Row alcoholics. Treatment
outcome data have
been especiallydifficult to obtain (4, 6, 7), and only tenuousconclusionsabouttreatmentcan be drawn from the smalland highly unrepresentativesamplesincluded in most studies. In the presentreportwe describean sx treatmentprogramand its patients. Data are presentedon treatment outcome and on the extent to which active involvementin the programrelates to outcome. Our focus is on the extent and manner
in which
one
s• programaffectedthe functioningof Skid Row alcoholics. • From the Social Ecology Laboratory, Department of Psychiatryand Behavioral Sciences,StanfordUniversity,and the VeteransAdministrationHospital, Palo Alto, CA
94304.
AC•CNOWLEDGMF. NTS.--Thisstudy was supportedin part by NIAAA Grant AA02863 and Veterans Administration Research Project MRIS 5817-01. We thank Fredric Bliss and Evelyn Bromet for facilitating the data collection and analysis. Receivedfor publication: 1 April 1977. Revision: 31 March 1978. 1267
]-•8
•. I-I. MOOS,B. MEHRENAND •B.S. MOOS METHODS
The s,aprogramunder studyis a 65-bedalcoholismtreatmentfacility locatedin a Skid Row districtnear the downtownarea of a large city. The facility offers a long-term recoveryprogram which emphasizes milieu therapy,includingxveeklytherapygroups,communitymeetings, Sundayworship servicesand religiouscounseling,educationallectures and films, A.A. meetings,and fellowshipand recreationalactivities.In addition,it housesa vocationalrehabilitationschool(training in printing and electronics),and placesthe residentsin "spot jobs" (casual labor) in the community.Vocationaltraining and counselingare considered important aspectsof rehabilitation.Residentsare encouraged to remain in the programfor 6 months,but the median length of stay was 63 days. Residentsare responsiblefor up to 50%of the program costs (monthly room and board fees), most of which is coveredby socialwelfare and incomefrom odd iobs while in residence.The staff
includesfour SalvationArmy officers,threeprofessional and eightparaprofessional therapistsand seven"client staff." Data on male residents were obtained from four sources:
The BackgroundInformationForm (mr), completedon admission, includedthe followingitems: (1) Alcoholconsumption (ouncesof ethanol consumedas beer, wine or distilled spirits in a typical day); (œ) Behavioralimpairment(the mean of 7 items, e.g., missingmeals due to drinking,rated on 5-pointscales);($) Physicalimpairment(the mean of 10 items, e.g., blackoutsand cold sweats,rated on 5-point scales);(4) Subjectiverating of drinkingproblem (1 = no problem, 5 -- quite often a problem); (5) Drinking pattern (a singleitem with 5 categoriesrangingfrom never drank to daily drinking); (6) Previous hospitalizationor residentialtreatment for alcoholismduring the 6 monthsprior to admission;(7) Occupational functioning(ever worked during the 6 monthsprior to admission);(8) Socialfunctioning(the mean of 5 items dealing with socialparticipationrated on 5-point scales);and (9) Psychological well-being(the mean of 6 items,e.g., beingin controlof your life, rated on 5-pointscales).A more complete descriptionof the items and subscales has been given by Brometet al. (8).
The Community-Oriented ProgramsEnvironmentScale(cOVES),completed 4 weeks after admission,was used to evaluate the socialclimate
of the s•, program(9, 10). Besidents and staff described the program by answeringtrue or false to 100 items, which fall into 10 subscales in 3 domains.Involvement,supportand spontaneitymeasurerelationshipdimensions; autonomy, practicalorientation,personalproblemorientation and anger and aggressionassessdimensionsrelevant to the type of treatmentprogram;and orderand organization, programclarity and staff controlassesssystemmaintenancedimensions. The treatmentexperiences in whicheachresidentactuallyparticipated were noted on the Treatment ExperiencesForm (xEv) by a staff member.The rangeof treatmentexperiences assessed includedpsyeho-
A SALVATION ARMY PROGRAM
1269
therapy and other group sessions,house meetings, A.A. attendance, educationalfilms related to alcoholism,Sunday worship and employment (spot iobs). Information about length of stay in the program was also collected.
The follow-up evaluation was obtained 6 months after discharge with the Follow-Up Information Form (FIF), a questionnaireidentical in content to the s•F administered
at intake
but with
one additional
item, abstinencesince discharge.The sI• categoriesrepresentedcriteria selectedto provide data on maior dimensionsof posttreatment functioning. The sI• and TE• data were obtained on all 121 patients; 109 completed the coPEsand 118 the FI•; 3 patientsdied during the follow-up period (11). I•ESULTS
Patient Backgroundand Functioningat Intake. Almost all the men were over age 40 (96•), the maiority(66%) being aged 40 to 59. Only 8%were married at intake, whereas61%were either separatedor divorced.Most of the men were White (93%), Protestants(52%) who either never (57%) or seldom(14•o) attended church.A total of 44%had completedhigh school,and a surprising 38• had vocationaltraining or somecollegeeducation,while 7• were collegegraduates.In light of this, it is important to note
that the maiority(56%)were last employedin unskilledor minimally skillediobs. Two factorscharacterizedtheir transientbehavior: 44%rented singleroomsand 43%had lived in their current residence for fewer than 3 months.
Intake statuson the nine outcomecriteriawas generallysymptomaticof severealcoholism,althougha few men, who had been
in detoxication and othertreatmentprograms iust beforeadmission, were already showingimprovedfunctioning.For example, over 90%of the men stated that their drinking was "often" or "quiteoften"a problemduringthe monthbeforeintake.Behavioral impairmentwas alsosevere:almost90%statedthat they had such problemsasmissingmealsor work due to drinking,drinkingwhile on the iob and drinkingin the morning.Over 75• indicateda high degreeof physicalimpairment,in that they had experienced deliriumtremensor "shakes," memorylapsesor blackoutsand severehangovers occasionally or frequentlyduringthe monthbefore intake.In addition,almost90%of the men statedthat they seldom if ever took part in socialactivities,and most were functioning at a relativelylow level of psychological well-being.
1270
•. i•. Moos, •. •E•mE• A•D •. S. MOOS
The SocialClimateof the SA Program.FigureI showsthe co•,Es profile of 109 residentsand 16 s•, staff. In general,residentsand staffhad similarperceptions of the sAsocialenvironment.Although they had averageor above averagescores(i.e., scoresof 50 or higher) on all dimensions, the relationshipdimensionsof involvement and support,the treatment program dimensionof practical orientation,and the systemmaintenancedimensionsof order and organizationand programclarity were emphasizedmost strongly. The profilesseem to reflect the generals•, treatment approach. Personalcontrol,the treatmentof the whole person,milieu therapy and practicalplanning for releaseare all important aspects of rehabilitation.Practicalorientationis exemplifiedby the training schoolhousedat the facility and by the importancegiven to working while in the program. Patient Functioningat Follow-Up. Chi-squareanalysesindicatedthat the s•,residentsshowedstatistically significant(p (.01) improvementon sevenof the nine outcomecriteria. Improvement on the drinking variablesof alcoholconsumption,behavioralimpairment,physicalimpairmentand subiectiverating of drinking problemwas considerable(Table 1). In addition, most men suf90•
C 0---.0
C Residents (N-J09) Staff (N-J6)
80-
q
50--
40
FIGURE1.--Mean COPES Scoreso•t SA Residentsand Staff
A SALVATION ARMY PROGRA1V•
1271
TABLE1.--SA Residents'Statusat Intake and at Follow-Up, and the Effects of Degree of Participation At Intake (N=97) Alcohol consumption (% 2 or less) 9.3 Behavioral impairment (% 2 or less) 11.3 Physical impairment (% 2 or less) 23.7 Rating of drinking problem (70 2 or less) 2.1 Hospitalization for alcoholism (% No) 64.9 Abstinentpast month (% Yes) 6.2 Occupational functioning (70 worked) 40.2 Social functioning (% 3 or more) 5.2 Psychologicalwell-being (% 3 or more) 18.6 * P < .05.
At PARTICIPATION Follow-up Low Medium (N=97) (N=24) (N--47)
High (N-----26)
xa
54.6•'
37.5
55.3
69.2
5.09
54.6•-
45.8
46.8
73.1
5.42
67.0vl '
37.5
46.8
73.1
7.14']'
46.4•-
25.0
51.1
57.7
6.16'
58.8
62.5
57.4
57.7
0.18
46.4•-
41.7
55.3
76.9
6.57*
61.9•-
70.8
61.7
53.8
1.53
11.3
37.5
44.7
69.2
5.87*
40.2•-
33.3
46.8
57.7
2.98
'• P < .01.
fered far fewer physicalconcomitants due to drinking, and occupationalfunctioningalsoimprovedsignificantly.Whereasonly 40•o of the men were employedat sometime duringthe 6 monthsbefore intake,62%were workingat sometime during the 6 months after discharge. ProgramParticipationand Functioningat Follow-Up. The sA programrelied almosttotally on psychotherapeutic and educational interventionssuchas grouppsychotherapy, housemeetings, educationalfilms and A.A. No drugs were administered.Participationin the two treatmentexperiences uniqueto sA,i.e., Sunday worshipand spotjobs,washigh. Ninety-nineper cent of the men went to Sunday worship at least once, and 62•oattended six or moreSundayservices;87%of the men worked on at least one spot job, while 645;workedat five or more. An index of programparticipationwas developedby combining the numberof times a residentparticipatedin each activity, and dividingthe total by the numberof dayshe spentin the program. The resultingvariable is a measureof how actively each man participatedin the program,independentof his length of stay. Chi-squareanalyseswere used to investigatethe relationship
1272
R. i-i, MOOS,B, MEHREI•Alii) B, S. MOOS
between residents'degree of participation(high, medium and low) and their statusat follow-up (dichotomizedas closeto the medianas possiblefor continuousoutcomecriteria). The three groupsshowedsignificantdifferences(p (.05) on four of the nine outcomecriteria (Table 1). The magnitudeof differences was quite substantial, e.g., 775 of the activelyparticipatinggroup had been abstinentduring the past month,and 735 complained of few if any physicalsymptomsdue to drinking,whereasthis was true of only 42 and 375 of their lessactivelyparticipating counterparts. Theseresultsindicatethat a resident'sactiveparticipationin the sAprogramis moderatelypredictiveof his statusat follow-up. ResidentsWho DroppedOut. The 265 who droppedout of the programwere comparedwith the remainderon the nine outcome
criteria.Only 28%of the drop-outshad been abstinentduringthe past month,comparedwith 53%of the others (p • .05). Fortyeightper centof the drop-outsstill reportedthat they had serious drinking problems,comparedwith only 21% of the remainder (p • .05). The drop-outswere alsomore likely to complainof physical symptoms(52 vs 265; p (.05), experiencebehavioralimpairment (48 vs 255; p (.06), and still be heavydrinkers(40 vs 175; p ( .05). On the otherhand,the two groupsdid not differ in occupational functioningor rehospitalization rates.Drop-outsthus tended to show poorer functioningat follow-up on most but not all of the outcome criteria.
An importantquestionis the extentto which droppingout can be predictedand perhapsprevented.The drop-outs perceivedthe sA treatmentmilieu more negativelythan did their counterparts: they perceivedsignificantly(p (.05) lessinvolvement,support, order and organization,and programclarity at s• than did the other group. DISCUSSION
The fact that the SAresidentsshowedstatisticallysignificant improvementon sevenof nine outcome criteria is consistentwith
recentliterature,which indicatesthat the maiorityof alcoholics improvewith treatment(8, 12, 13). A six-monthfollow-upseems to providea stableindicatorof grouprecoveryrates (12, 14, 15). In addition, since 82%of the original cohort were successfully
A SALVATIONARI•[Y PROGRAM
1273
traced,the sampleprobablyincludesmany of the more poorly functioningalcoholics who are usuallynot includedin outcome studies (11).
Treatmentoutcomecomparedfavorablywith that in four other alcoholism treatmentprograms participating in our over-allstudy (10). Two treatmentsettings, a halfwayhouseand a hospitalbasedprogram,were comparable to sAin patients'socioeconomic composition and other demographic background characteristics. SApatientsshowedas goodor betterimprovement than did the hospitalpatientson all outcome measures exceptabstinence, and compared favorablyto the halfway-house sampleon six of the nine outcomemeasures. Thus,the SAprogramwas generallydoing at least as well as other similartreatmentprograms.Two salient
program characteristics, socialclimateandtreatment approach, are uniqueandintegralto sA,andseemto contribute to its treatment StlCCCSS.
The COPES profilesindicatean integratedand cohesive social environment. Staff-resident congruence on the coPEsprofileindicatesthat staff have an accurateperceptionof the program,are in touchwith the residents,and are in agreementwith the resi-
dents'perceptions of the program.The relativestabilityof the program overtime,asshownby coPEs profileswe obtained about 6 monthsapart,is probablydue to the high congruence between residentsand staff, and to their relative satisfactionwith the pro-
gram.This SAprogramthuspresents an over-allpictureof congruenceand stability.
Treatmentat sAemphasizes the over-allfunctioning of the patient,ratherthanonlythereduction or elimination of hisdrinking. Two treatmentexperiences are uniqueto SAand illustratethis emphasis: Sunday worship andspotiobs.Whatever the reason for including iobsandworship in treatment, theyseemto contribute to significant improvement in occupational, behavioral andpsychologicalfunctioning. Katz(1) foundthatparticipation in vocational counseling in an sAprogram wasstronglyrelatedto laterimprovement.
In general, studies of alcoholism treatment differasto the relative importanceof differenttypesof treatment,participationin treatmentand its length (12, 15, 16). The presentfindingssup-
portthenotionthatthe activeinvolvement of the patientin the program maybe themostimportant factor.Theresidents' over-all degreeof participation waspositively relatedto betteroutcome,
1274
•t. H. MOOS,B. MEI-IRENAND 13.S. MOOS
even after length of stay was controlled.In addition,thosewho droppedout (who were presumablynot as integratedinto the sAprogram)did not do as well at follow-upas did the oneswho remained.
Drop-outsperceivedthe socialclimate more negatively,suggestingthat early identificationof potential programdrop-outs is a practicalpossibility.In this connection, Chase(17) reported that residents'perceptionsof the social climate, irrespectiveof when they were obtainedduring treatment,were a major componentin predictingwho would remain in treatment.Since the drop-outstendedto functionmore poorlyat follow-upthan did thosewho remained,it might be helpful to identify and direct specialattentiontowardthemearly in the program.The finding that alcoholicswho perceive their treatment environmentmore positivelyare more likely to participatein aftercareservicessupportsthe importance of theseconsiderations (18). Evidently,both the socialclimate and treatmentexperiences contributeto make SAa successfulalcoholismtreatment program.
The sAprogramis alsorelativelyinexpensive, sinceit basicallypays for itselfwhenincomefromresidents' spotjobsis considered. Armor et al. (12) havesuggested that, sinceall alcoholism treatment programs producesimilarresults, the leastcostlytreatmentmethod should be used. However, it would be hazardousto assumethat all alcoholicswould be treated effectivelyin an sA-typeprogram.
SA programsseemto be uniquelybeneficialfor Skid Row alcoholics,but the extent to which this type of programcan be effectivelyappliedto a broaderrangeof alcoholicpatientsremains to be determined.
REFERENCES
1. K,•I'z, L. The SalvationArlny Men's Social ServiceCenter. I. Program.Q. J. Stud. Alcohol 25: 324-332,
1964.
2. K,•TZ, L. The SalvationArmy Men's SocialServiceCenter.II. Results.Q. J. Stud. Alcohol 27: 636-647, 1966.
3. FaZZL,•ND, L. C. The SalvationArmy. Pp. 351-361. In: C,•T,•NZ,•aO, R. J., ed. Alcoholism;the total treatment approach.Springfield, IL; Thomas; 1968. 4. JVDCE, J. J. Alcoholisin treatmentat the SalvationArmy; a new Men'sSocial ServiceCenter program.Q. J. Stud. Alcohol 32: 462-467, 1971. 5. WisEnaN,J.P. Stations of thelost;the treatment of SkidRowalcoholics. Englexvood Cliffs, NJ; Prentice-Hall; 1970.
A SALVATION ARMY PROGRAm(
1275
6. BLUMBERG,L. U., SHIPLE¾,T. E., Jn. and MooR, J. O., JR. The Skid Row man and the Skid Row status community with perspectiveson their future. Q. J. Stud. Alcohol 32: 909-941, 1971. 7. FELDI•IAN,J., Su, W.-II., KALEY, M. M. and KISSIN, B. Skid Row and innercity alcoholics;a comparisonof drinking patterns and medical problems. Q. J. Stud. Alcohol 35: 565-576, 1974. 8. BROMET,E., Moos, R. H., BLISS,F. and WUTHMANN, C. The posttreatment functioning of alcoholic patients; its relation to prograin participation. J. Consult. Clin. Psychol. 45: 829-842, 1977. 9. Moos, R. H. Evaluating treatment environments;a social ecologicalapproach. New York; Wiley; 1974.
10. Moos, R. H. Community-oriented programsenvironmentscale manual. Palo Alto, CA; Consulting PsychologistsPress; 1974. 11. Moos, R. and BLISS, 17. Difficulty of follow-up and outcome of alcoholism treatment. J. Stud. Alcohol 39: 473-490, 1978. 12. ARMOR, D. J., POLICH,J. M. and STAMBUL,H. B. Alcoholism and treatment. Prepared for the U.S. National Institute on Alcohol Abuse and Alcoholism. Santa Monica, CA; Rand Corporation; 1976. 13. RUGGELS,W. L., ARMOR,D. J., POLICIt, J. M., MOTHERSHEAD, A. and STEPHEN, M. A follow-up study of clients at selected alcoholism treatment centers funded by National Institute on Alcohol Abuse and Alcoholism;final report. Prepared for the U.S. National Institute on Alcohol Abuse and Alcoholism, Rockville, MD. Menlo Park, CA; Stanford Research Institute; 1975. 14. POKORNY,A. D., MILLER, B. A. and CLEVELAND,S. E. Responseto treatment of alcoholism;a follow-up study. Q. J. Stud. Alcohol 29: 364-381, 1968. 15. WILLEMS,P. J. A., LETEMENDIA,F. J. A. and ARRO'•AVV., F. A two-year followup study comparing short with long stay in-patient treatment of alcoholics. Br. J. Psychiat. 122: 637-648, 1973. 16. CRAFT, J. E., SHEEHAN,D. M., DRICCERS,J. M. Components of effectiveness in alcoholismtreatment programs.Vol. 5. Correlatesof treatment outcomes. Austin; Texas Dept. of Mental Health and Mental Retardation; 1975. 17. CHASE,M. The impact of correctionalprograms; absconding.In: Moos, R. H. Evaluating correctionaland community settings.New York; Wiley; 1975. 18. PRATT, T. C., LINN, M. W., CARMICHAEL,J. S. and WEBB, N. L. The alcoholic'sperceptionof the ward as a predictor of aftercare attendance.J. Clin. Psychol. 33: 915-918, 1977.
Evaluationof a SalvationArmy Alcoholism TreatmentProgram' Rudolf H. Moos, Barbara Mehren and Bernice S. Moos SUMMARY. The functioningand participationo[ 97 men in a treatmentprogram were analyzedin what was judged to be a cost-e[[ectiveprogram [or Skid Row alcoholics.
HE SALVATION ARMY (sa) has been looking after al-
coholicsfor more than a century,and now treatswell over 50,000annuallyin the United States.The sa programsare unusualin the variety of treatmentsthey offer, includinggroup and individualtherapy,milieu therapy and participationin AlcoholicsAnonymous, and in their strongemphasison vocationaltraining and religiousand spiritualcounseling. Despite its unique scope and character,the impact of sA'streatment regimen on the rehabilitationof alcoholicshas not often been studied (1-4). There is a sizeablebody of literature on Skid Row, but most studieshave been sociological reconstructions of Skid Row society (e.g., 5, 6). Little systematicresearchdeals specificallywith the treatment
of Skid Row alcoholics. Treatment
outcome data have
been especiallydifficult to obtain (4, 6, 7), and only tenuousconclusionsabouttreatmentcan be drawn from the smalland highly unrepresentativesamplesincluded in most studies. In the presentreportwe describean sx treatmentprogramand its patients. Data are presentedon treatment outcome and on the extent to which active involvementin the programrelates to outcome. Our focus is on the extent and manner
in which
one
s• programaffectedthe functioningof Skid Row alcoholics. • From the Social Ecology Laboratory, Department of Psychiatryand Behavioral Sciences,StanfordUniversity,and the VeteransAdministrationHospital, Palo Alto, CA
94304.
AC•CNOWLEDGMF. NTS.--Thisstudy was supportedin part by NIAAA Grant AA02863 and Veterans Administration Research Project MRIS 5817-01. We thank Fredric Bliss and Evelyn Bromet for facilitating the data collection and analysis. Receivedfor publication: 1 April 1977. Revision: 31 March 1978. 1267
]-•8
•. I-I. MOOS,B. MEHRENAND •B.S. MOOS METHODS
The s,aprogramunder studyis a 65-bedalcoholismtreatmentfacility locatedin a Skid Row districtnear the downtownarea of a large city. The facility offers a long-term recoveryprogram which emphasizes milieu therapy,includingxveeklytherapygroups,communitymeetings, Sundayworship servicesand religiouscounseling,educationallectures and films, A.A. meetings,and fellowshipand recreationalactivities.In addition,it housesa vocationalrehabilitationschool(training in printing and electronics),and placesthe residentsin "spot jobs" (casual labor) in the community.Vocationaltraining and counselingare considered important aspectsof rehabilitation.Residentsare encouraged to remain in the programfor 6 months,but the median length of stay was 63 days. Residentsare responsiblefor up to 50%of the program costs (monthly room and board fees), most of which is coveredby socialwelfare and incomefrom odd iobs while in residence.The staff
includesfour SalvationArmy officers,threeprofessional and eightparaprofessional therapistsand seven"client staff." Data on male residents were obtained from four sources:
The BackgroundInformationForm (mr), completedon admission, includedthe followingitems: (1) Alcoholconsumption (ouncesof ethanol consumedas beer, wine or distilled spirits in a typical day); (œ) Behavioralimpairment(the mean of 7 items, e.g., missingmeals due to drinking,rated on 5-pointscales);($) Physicalimpairment(the mean of 10 items, e.g., blackoutsand cold sweats,rated on 5-point scales);(4) Subjectiverating of drinkingproblem (1 = no problem, 5 -- quite often a problem); (5) Drinking pattern (a singleitem with 5 categoriesrangingfrom never drank to daily drinking); (6) Previous hospitalizationor residentialtreatment for alcoholismduring the 6 monthsprior to admission;(7) Occupational functioning(ever worked during the 6 monthsprior to admission);(8) Socialfunctioning(the mean of 5 items dealing with socialparticipationrated on 5-point scales);and (9) Psychological well-being(the mean of 6 items,e.g., beingin controlof your life, rated on 5-pointscales).A more complete descriptionof the items and subscales has been given by Brometet al. (8).
The Community-Oriented ProgramsEnvironmentScale(cOVES),completed 4 weeks after admission,was used to evaluate the socialclimate
of the s•, program(9, 10). Besidents and staff described the program by answeringtrue or false to 100 items, which fall into 10 subscales in 3 domains.Involvement,supportand spontaneitymeasurerelationshipdimensions; autonomy, practicalorientation,personalproblemorientation and anger and aggressionassessdimensionsrelevant to the type of treatmentprogram;and orderand organization, programclarity and staff controlassesssystemmaintenancedimensions. The treatmentexperiences in whicheachresidentactuallyparticipated were noted on the Treatment ExperiencesForm (xEv) by a staff member.The rangeof treatmentexperiences assessed includedpsyeho-
A SALVATION ARMY PROGRAM
1269
therapy and other group sessions,house meetings, A.A. attendance, educationalfilms related to alcoholism,Sunday worship and employment (spot iobs). Information about length of stay in the program was also collected.
The follow-up evaluation was obtained 6 months after discharge with the Follow-Up Information Form (FIF), a questionnaireidentical in content to the s•F administered
at intake
but with
one additional
item, abstinencesince discharge.The sI• categoriesrepresentedcriteria selectedto provide data on maior dimensionsof posttreatment functioning. The sI• and TE• data were obtained on all 121 patients; 109 completed the coPEsand 118 the FI•; 3 patientsdied during the follow-up period (11). I•ESULTS
Patient Backgroundand Functioningat Intake. Almost all the men were over age 40 (96•), the maiority(66%) being aged 40 to 59. Only 8%were married at intake, whereas61%were either separatedor divorced.Most of the men were White (93%), Protestants(52%) who either never (57%) or seldom(14•o) attended church.A total of 44%had completedhigh school,and a surprising 38• had vocationaltraining or somecollegeeducation,while 7• were collegegraduates.In light of this, it is important to note
that the maiority(56%)were last employedin unskilledor minimally skillediobs. Two factorscharacterizedtheir transientbehavior: 44%rented singleroomsand 43%had lived in their current residence for fewer than 3 months.
Intake statuson the nine outcomecriteriawas generallysymptomaticof severealcoholism,althougha few men, who had been
in detoxication and othertreatmentprograms iust beforeadmission, were already showingimprovedfunctioning.For example, over 90%of the men stated that their drinking was "often" or "quiteoften"a problemduringthe monthbeforeintake.Behavioral impairmentwas alsosevere:almost90%statedthat they had such problemsasmissingmealsor work due to drinking,drinkingwhile on the iob and drinkingin the morning.Over 75• indicateda high degreeof physicalimpairment,in that they had experienced deliriumtremensor "shakes," memorylapsesor blackoutsand severehangovers occasionally or frequentlyduringthe monthbefore intake.In addition,almost90%of the men statedthat they seldom if ever took part in socialactivities,and most were functioning at a relativelylow level of psychological well-being.
1270
•. i•. Moos, •. •E•mE• A•D •. S. MOOS
The SocialClimateof the SA Program.FigureI showsthe co•,Es profile of 109 residentsand 16 s•, staff. In general,residentsand staffhad similarperceptions of the sAsocialenvironment.Although they had averageor above averagescores(i.e., scoresof 50 or higher) on all dimensions, the relationshipdimensionsof involvement and support,the treatment program dimensionof practical orientation,and the systemmaintenancedimensionsof order and organizationand programclarity were emphasizedmost strongly. The profilesseem to reflect the generals•, treatment approach. Personalcontrol,the treatmentof the whole person,milieu therapy and practicalplanning for releaseare all important aspects of rehabilitation.Practicalorientationis exemplifiedby the training schoolhousedat the facility and by the importancegiven to working while in the program. Patient Functioningat Follow-Up. Chi-squareanalysesindicatedthat the s•,residentsshowedstatistically significant(p (.01) improvementon sevenof the nine outcomecriteria. Improvement on the drinking variablesof alcoholconsumption,behavioralimpairment,physicalimpairmentand subiectiverating of drinking problemwas considerable(Table 1). In addition, most men suf90•
C 0---.0
C Residents (N-J09) Staff (N-J6)
80-
q
50--
40
FIGURE1.--Mean COPES Scoreso•t SA Residentsand Staff
A SALVATION ARMY PROGRA1V•
1271
TABLE1.--SA Residents'Statusat Intake and at Follow-Up, and the Effects of Degree of Participation At Intake (N=97) Alcohol consumption (% 2 or less) 9.3 Behavioral impairment (% 2 or less) 11.3 Physical impairment (% 2 or less) 23.7 Rating of drinking problem (70 2 or less) 2.1 Hospitalization for alcoholism (% No) 64.9 Abstinentpast month (% Yes) 6.2 Occupational functioning (70 worked) 40.2 Social functioning (% 3 or more) 5.2 Psychologicalwell-being (% 3 or more) 18.6 * P < .05.
At PARTICIPATION Follow-up Low Medium (N=97) (N=24) (N--47)
High (N-----26)
xa
54.6•'
37.5
55.3
69.2
5.09
54.6•-
45.8
46.8
73.1
5.42
67.0vl '
37.5
46.8
73.1
7.14']'
46.4•-
25.0
51.1
57.7
6.16'
58.8
62.5
57.4
57.7
0.18
46.4•-
41.7
55.3
76.9
6.57*
61.9•-
70.8
61.7
53.8
1.53
11.3
37.5
44.7
69.2
5.87*
40.2•-
33.3
46.8
57.7
2.98
'• P < .01.
fered far fewer physicalconcomitants due to drinking, and occupationalfunctioningalsoimprovedsignificantly.Whereasonly 40•o of the men were employedat sometime duringthe 6 monthsbefore intake,62%were workingat sometime during the 6 months after discharge. ProgramParticipationand Functioningat Follow-Up. The sA programrelied almosttotally on psychotherapeutic and educational interventionssuchas grouppsychotherapy, housemeetings, educationalfilms and A.A. No drugs were administered.Participationin the two treatmentexperiences uniqueto sA,i.e., Sunday worshipand spotjobs,washigh. Ninety-nineper cent of the men went to Sunday worship at least once, and 62•oattended six or moreSundayservices;87%of the men worked on at least one spot job, while 645;workedat five or more. An index of programparticipationwas developedby combining the numberof times a residentparticipatedin each activity, and dividingthe total by the numberof dayshe spentin the program. The resultingvariable is a measureof how actively each man participatedin the program,independentof his length of stay. Chi-squareanalyseswere used to investigatethe relationship
1272
R. i-i, MOOS,B, MEHREI•Alii) B, S. MOOS
between residents'degree of participation(high, medium and low) and their statusat follow-up (dichotomizedas closeto the medianas possiblefor continuousoutcomecriteria). The three groupsshowedsignificantdifferences(p (.05) on four of the nine outcomecriteria (Table 1). The magnitudeof differences was quite substantial, e.g., 775 of the activelyparticipatinggroup had been abstinentduring the past month,and 735 complained of few if any physicalsymptomsdue to drinking,whereasthis was true of only 42 and 375 of their lessactivelyparticipating counterparts. Theseresultsindicatethat a resident'sactiveparticipationin the sAprogramis moderatelypredictiveof his statusat follow-up. ResidentsWho DroppedOut. The 265 who droppedout of the programwere comparedwith the remainderon the nine outcome
criteria.Only 28%of the drop-outshad been abstinentduringthe past month,comparedwith 53%of the others (p • .05). Fortyeightper centof the drop-outsstill reportedthat they had serious drinking problems,comparedwith only 21% of the remainder (p • .05). The drop-outswere alsomore likely to complainof physical symptoms(52 vs 265; p (.05), experiencebehavioralimpairment (48 vs 255; p (.06), and still be heavydrinkers(40 vs 175; p ( .05). On the otherhand,the two groupsdid not differ in occupational functioningor rehospitalization rates.Drop-outsthus tended to show poorer functioningat follow-up on most but not all of the outcome criteria.
An importantquestionis the extentto which droppingout can be predictedand perhapsprevented.The drop-outs perceivedthe sA treatmentmilieu more negativelythan did their counterparts: they perceivedsignificantly(p (.05) lessinvolvement,support, order and organization,and programclarity at s• than did the other group. DISCUSSION
The fact that the SAresidentsshowedstatisticallysignificant improvementon sevenof nine outcome criteria is consistentwith
recentliterature,which indicatesthat the maiorityof alcoholics improvewith treatment(8, 12, 13). A six-monthfollow-upseems to providea stableindicatorof grouprecoveryrates (12, 14, 15). In addition, since 82%of the original cohort were successfully
A SALVATIONARI•[Y PROGRAM
1273
traced,the sampleprobablyincludesmany of the more poorly functioningalcoholics who are usuallynot includedin outcome studies (11).
Treatmentoutcomecomparedfavorablywith that in four other alcoholism treatmentprograms participating in our over-allstudy (10). Two treatmentsettings, a halfwayhouseand a hospitalbasedprogram,were comparable to sAin patients'socioeconomic composition and other demographic background characteristics. SApatientsshowedas goodor betterimprovement than did the hospitalpatientson all outcome measures exceptabstinence, and compared favorablyto the halfway-house sampleon six of the nine outcomemeasures. Thus,the SAprogramwas generallydoing at least as well as other similartreatmentprograms.Two salient
program characteristics, socialclimateandtreatment approach, are uniqueandintegralto sA,andseemto contribute to its treatment StlCCCSS.
The COPES profilesindicatean integratedand cohesive social environment. Staff-resident congruence on the coPEsprofileindicatesthat staff have an accurateperceptionof the program,are in touchwith the residents,and are in agreementwith the resi-
dents'perceptions of the program.The relativestabilityof the program overtime,asshownby coPEs profileswe obtained about 6 monthsapart,is probablydue to the high congruence between residentsand staff, and to their relative satisfactionwith the pro-
gram.This SAprogramthuspresents an over-allpictureof congruenceand stability.
Treatmentat sAemphasizes the over-allfunctioning of the patient,ratherthanonlythereduction or elimination of hisdrinking. Two treatmentexperiences are uniqueto SAand illustratethis emphasis: Sunday worship andspotiobs.Whatever the reason for including iobsandworship in treatment, theyseemto contribute to significant improvement in occupational, behavioral andpsychologicalfunctioning. Katz(1) foundthatparticipation in vocational counseling in an sAprogram wasstronglyrelatedto laterimprovement.
In general, studies of alcoholism treatment differasto the relative importanceof differenttypesof treatment,participationin treatmentand its length (12, 15, 16). The presentfindingssup-
portthenotionthatthe activeinvolvement of the patientin the program maybe themostimportant factor.Theresidents' over-all degreeof participation waspositively relatedto betteroutcome,
1274
•t. H. MOOS,B. MEI-IRENAND 13.S. MOOS
even after length of stay was controlled.In addition,thosewho droppedout (who were presumablynot as integratedinto the sAprogram)did not do as well at follow-upas did the oneswho remained.
Drop-outsperceivedthe socialclimate more negatively,suggestingthat early identificationof potential programdrop-outs is a practicalpossibility.In this connection, Chase(17) reported that residents'perceptionsof the social climate, irrespectiveof when they were obtainedduring treatment,were a major componentin predictingwho would remain in treatment.Since the drop-outstendedto functionmore poorlyat follow-upthan did thosewho remained,it might be helpful to identify and direct specialattentiontowardthemearly in the program.The finding that alcoholicswho perceive their treatment environmentmore positivelyare more likely to participatein aftercareservicessupportsthe importance of theseconsiderations (18). Evidently,both the socialclimate and treatmentexperiences contributeto make SAa successfulalcoholismtreatment program.
The sAprogramis alsorelativelyinexpensive, sinceit basicallypays for itselfwhenincomefromresidents' spotjobsis considered. Armor et al. (12) havesuggested that, sinceall alcoholism treatment programs producesimilarresults, the leastcostlytreatmentmethod should be used. However, it would be hazardousto assumethat all alcoholicswould be treated effectivelyin an sA-typeprogram.
SA programsseemto be uniquelybeneficialfor Skid Row alcoholics,but the extent to which this type of programcan be effectivelyappliedto a broaderrangeof alcoholicpatientsremains to be determined.
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1. K,•I'z, L. The SalvationArlny Men's Social ServiceCenter. I. Program.Q. J. Stud. Alcohol 25: 324-332,
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2. K,•TZ, L. The SalvationArmy Men's SocialServiceCenter.II. Results.Q. J. Stud. Alcohol 27: 636-647, 1966.
3. FaZZL,•ND, L. C. The SalvationArmy. Pp. 351-361. In: C,•T,•NZ,•aO, R. J., ed. Alcoholism;the total treatment approach.Springfield, IL; Thomas; 1968. 4. JVDCE, J. J. Alcoholisin treatmentat the SalvationArmy; a new Men'sSocial ServiceCenter program.Q. J. Stud. Alcohol 32: 462-467, 1971. 5. WisEnaN,J.P. Stations of thelost;the treatment of SkidRowalcoholics. Englexvood Cliffs, NJ; Prentice-Hall; 1970.
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6. BLUMBERG,L. U., SHIPLE¾,T. E., Jn. and MooR, J. O., JR. The Skid Row man and the Skid Row status community with perspectiveson their future. Q. J. Stud. Alcohol 32: 909-941, 1971. 7. FELDI•IAN,J., Su, W.-II., KALEY, M. M. and KISSIN, B. Skid Row and innercity alcoholics;a comparisonof drinking patterns and medical problems. Q. J. Stud. Alcohol 35: 565-576, 1974. 8. BROMET,E., Moos, R. H., BLISS,F. and WUTHMANN, C. The posttreatment functioning of alcoholic patients; its relation to prograin participation. J. Consult. Clin. Psychol. 45: 829-842, 1977. 9. Moos, R. H. Evaluating treatment environments;a social ecologicalapproach. New York; Wiley; 1974.
10. Moos, R. H. Community-oriented programsenvironmentscale manual. Palo Alto, CA; Consulting PsychologistsPress; 1974. 11. Moos, R. and BLISS, 17. Difficulty of follow-up and outcome of alcoholism treatment. J. Stud. Alcohol 39: 473-490, 1978. 12. ARMOR, D. J., POLICH,J. M. and STAMBUL,H. B. Alcoholism and treatment. Prepared for the U.S. National Institute on Alcohol Abuse and Alcoholism. Santa Monica, CA; Rand Corporation; 1976. 13. RUGGELS,W. L., ARMOR,D. J., POLICIt, J. M., MOTHERSHEAD, A. and STEPHEN, M. A follow-up study of clients at selected alcoholism treatment centers funded by National Institute on Alcohol Abuse and Alcoholism;final report. Prepared for the U.S. National Institute on Alcohol Abuse and Alcoholism, Rockville, MD. Menlo Park, CA; Stanford Research Institute; 1975. 14. POKORNY,A. D., MILLER, B. A. and CLEVELAND,S. E. Responseto treatment of alcoholism;a follow-up study. Q. J. Stud. Alcohol 29: 364-381, 1968. 15. WILLEMS,P. J. A., LETEMENDIA,F. J. A. and ARRO'•AVV., F. A two-year followup study comparing short with long stay in-patient treatment of alcoholics. Br. J. Psychiat. 122: 637-648, 1973. 16. CRAFT, J. E., SHEEHAN,D. M., DRICCERS,J. M. Components of effectiveness in alcoholismtreatment programs.Vol. 5. Correlatesof treatment outcomes. Austin; Texas Dept. of Mental Health and Mental Retardation; 1975. 17. CHASE,M. The impact of correctionalprograms; absconding.In: Moos, R. H. Evaluating correctionaland community settings.New York; Wiley; 1975. 18. PRATT, T. C., LINN, M. W., CARMICHAEL,J. S. and WEBB, N. L. The alcoholic'sperceptionof the ward as a predictor of aftercare attendance.J. Clin. Psychol. 33: 915-918, 1977.
