CAUTION: This is the text underlying the published version of the same bulletin entry. It may not incorporate late revisions and corrections. Neither the text nor the citations were finalised for publication so may be inconsistently presented and sometimes take the form of notes rather than polished text. It is offered as a source of additional information and citations but should not be relied on, especially when it departs from the published version available at:
http://findings.org.uk/count/downloads/download.php?file=reminders.nug. For further information or to comment on this draft contact editor@findings.org.uk.
© Drug and Alcohol Findings 2008. Permission is given to distribute this document unamended electronically or on paper or to incorporate passages in other documents as long as the source and copyright owner are acknowledged including the web address http://findings.org.uk.

Bulletin November 2008
Systematic, persistent and welcoming aftercare prompts preserve benefits of residential care
A US inpatient treatment centre has shown that systematically applying simple prompts and motivators can substantially improve aftercare attendance and help sustain progress made during initial treatment. The findings offer a way to preserve the benefits of the considerable investment made by patients, services, and funders.
FINDINGS The Salem Veterans Affairs medical centre in Virginia offers a 28-day residential rehabilitation programme run on cognitive-behavioural lines to its alcohol and/or drug dependent, ex-military patients. To sustain sobriety, staff stressed the importance of attending weekly aftercare groups, but few patients did so and attendance was poor. A unique series of studies    had previously shown that attendance radically improved as step by step, researchers added enhancements to test their ‘added value’. The series culminated in a report which suggested (but the samples were small) that there were consequent reductions in substance use and related problems up to a year after treatment entry.
A new study has now tested the impact of the entire package (plus further enhancements) on aftercare attendance and more robustly assessed resultant improvements in substance use. After just 11 refusals, 150 eligible patients agreed to join the study and were randomly allocated to the centre’s standard procedure or to the enhanced package. 
During the final week of their stay, standard procedure patients were encouraged to attend the centre’s aftercare groups and individual aftercare therapy sessions, as well as to engage with mutual aid groups such as NA and AA. Initial appointments and/or attendance schedules were agreed and listed in an aftercare ‘contract’ handed to the patient, who was also shown a motivational video.
In the enhanced version, the contract was strengthened by explicitly asking patients to commit over the next eight weeks to attend weekly groups and AA/NA meetings and monthly individual sessions, only missing these in an emergency. The schedule and initial appointments were completed by the patients themselves who signed and dated the contract which was ‘witnessed’ by the therapist. Veterans Affairs’ data showing that aftercare attendance was associated with better abstinence outcomes was used to motivate agreement. The aim was to retain patients for at least three months of treatment overall, the minimum associated with improved treatment outcomes in this population. Therapists also explained the reminder system and showed patients the awards for good attendance specified in the contract. After eight weeks patients were invited to re-contract to continue in aftercare for a year in total.
Letters from the patient’s individual therapist saying they were pleased the client had chosen to join them and that they looked forward to seeing them, appointment cards (which also tallied the patient’s attendance to date) and automated telephone reminders, prompted patients to attend the next session in a few days time. Non-attendance was followed by a letter and phone call from the therapist. 
The awards consisted of medallions and certificates given the patient during individual aftercare sessions. Further reinforcement took the form of a handwritten letter after their first aftercare group session congratulating the patient on initiating aftercare followed by another after three sessions. 
Researchers unaware of which procedure patients had been allocated to were able to re-assess around 80% two, five and 11 months after they left treatment, reassuring them that their responses were confidential. Urinalysis results confirmed the accuracy of their answers regarding substance use. 
Compared to the standard procedure, the enhancements led 12% (95% v. 83%) more patients to initiate aftercare and nearly 30% more (75% v. 45%) to attend at least two sessions a month over the first two months. Attendance tailed off until after five months just 20–25% remained continuously in aftercare and after 11 months 12–13%. Though on these measures there was no persisting impact of the interventions, still nearly twice as many intervention patients attended some form of aftercare (including mutual aid groups) during the last three months of the follow-up (40% v. 22%). 
It was this persisting attendance advantage which appeared to account at least in part for impacts on substance use. Eleven months after leaving treatment, nearly 20% more (57% v. 37%) enhanced patients had been abstinent from alcohol and drugs for the past three months. The difference had grown over the preceding six months as more of these patients stopped using. In contrast, the average intensity of substance use did not differ between the two sets of patients and nor generally did the severity of related problems. 
IN CONTEXT Because the centre served ex-military personnel there were very few women. All the studies excluded participants who would have had significant difficulty getting to an aftercare centre due to distance, lack of transport or work commitments. Eliminating these practical barriers to attendance probably allowed the influence of what happens in treatment to show through so clearly.
The strongest attendance gains were observed when the contracting and rewarding procedures were also at their height (the first two months) and for the type of aftercare provision (the centre’s own sessions) most explicitly targeted. From the prior studies, we know that each of the elements in the package added to its impact. Involving the patients themselves in formulating the contract seems likely to have deepened their commitment to fulfilling it. By signing it they acknowledged research data indicating that aftercare tripled the chances of staying sober. Only those prepared to admit to themselves and to their therapist that they did not wish to improve their chances in this way would have been able to resist. Personal, handwritten letters from therapists and their phone calls signified individual attention and that someone cared enough to notice the patient’s achievements and to bother when they went missing. The pattern of abstinence outcomes suggests that the intervention patients, systematically encouraged and prompted to stay in or return to aftercare, felt more inclined to seek help after they lapsed or relapsed. A welcoming, non-punitive (‘Come back – we’d like to see you’) attitude would have made it easier for the patient. The result it seemed was that more resumed abstinence over the last few months of the follow-up.
Substantial as they were, the gains from the enhanced package may be greater if it replaces procedures typical in many centres. The standard procedure was itself an advance on the most basic procedure tested in an earlier study and probably also on what typically happens to encourage aftercare attendance. Compared to minimal or less systematic procedures, the whole package tested in the featured study should make an even greater difference to attendance and outcomes. It might have been more powerful still if (as in a previous study) the awards had been made in front of peers at the group therapy sessions, an opportunity which had to be foregone because some of the patients in each group would have been from the standard care set.
Outcomes were substantially unaltered when it was assumed that patients unable to be followed up were continuing to use alcohol or drugs.
The prior studies from Salem and related studies have previously been reviewed by Drug and Alcohol Findings in parts one and two of the Manners Matter series. These concluded that treating the addict or alcoholic as an individual human being, being welcoming, and showing respect and caring persistence, are among the hallmarks of services which retain clients either initially or in aftercare. The reviews argued that there is no conflict between these qualities and efficient administrative procedures of the kind used to deliver reminders in the featured study. To the contrary, such procedures are needed to give practical expression to the qualities and values which motivate them. In turn, these procedures will not have the desired impact unless they express these qualities; a cold or standardised reminder letter signifies that the sender cares little whether the individual turns up or not. Personal approaches are more effective at encouraging attendance. 
PRACTICE IMPLICATIONS Behind the intervention is the principle of prompting and rewarding attendance directly and immediately rather than expecting this to be motivated entirely by the patient’s interest in their long-term recovery. Manual and materials and related publications are available free of charge from the lead author at Steven.Lash@va.gov. The interventions are practical in terms of low staff time and resource commitment, and probably also widely acceptable to patients, services, funders and the public because they neither involve material rewards, nor material or other sanctions. Instead they systematise good reminder procedures and a welcoming, positive attitude, and draw on a relevant evidence base to help persuade them of the benefits of aftercare take-up. 
If, as is being strongly argued in some quarters, Britain is to re-balance its treatment system to offer more residential treatment slots, aftercare provision and encouragement of the kind trialed in the study will be crucial to help patients avoid or overcome lapses or relapses, and to sustain support for services which might otherwise be seen as costly revolving doors. These settings radically alter the patient’s social and physical environment, enabling residents who would otherwise be unable to do so to attain abstinence. By the same token, unless steps have been taken to alter this or sustainably alter how the patient reacts to it, they are likely to relapse when they return to the environments in which they were previously unable to stop using. For heroin dependent patients in particular, aftercare should arguably be even more intensive and energetically encouraged to avoid the risk of overdose due to relapse at a time when the patient has lost their tolerance to opiate-type drugs. In the English NTORS study, within a fortnight of leaving residential or inpatient care, half the former heroin users had returned to the drug. In other studies the consequence has been extremely high post-discharge death rates. 
Guidance on residential services in England stresses that “Service users leaving residential rehabilitation need aftercare to support consolidation of their treatment gain” and that “Detoxification‑only interventions should be followed by a period of psychosocial treatment”. Unlike in the featured study, arrangements are often complicated by the fact that residents return to their home areas, beyond the reach of direct aftercare provision by the initial service provider. Most services do make some arrangements but 4 in 10 surveyed residents were at best unclear who was to coordinate their aftercare when they left and care plans appeared to rely on mutual aid groups for the resident’s ongoing psychosocial support. Valuable as they are, arranging and monitoring attendance and responding to missed meetings is less feasible than doing the same in respect of formal aftercare arrangements.