Faith-Intensive and Secular Substance Abuse Treatment Services

Transcription

1 FAITH-BASED SOCIAL SERVICES APRIL 2011 Patient Characteristics Outcomes Final Report By Thomas L. Gais, The Rockefeller Institute of Government Amelia Arria, University of Maryl School of Public Health The Public Policy Research Arm of the State University of New York 411 State Street Albany, NY (518)

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3 Faith-Based FAITH-BASED SOCIAL SERVICES Contents Executive Summary...vi Introduction...1 Policy Context Significance of the Study...5 Background Preliminary Studies...7 Hypotheses...12 Phase II: A Preliminary Multivariate Correlational Analysis...15 Phase II: The Field Experiment Its Implementation...17 Interview Measures...26 Characteristics of Participants in Experiment...29 Religiosity Among Participants...37 Relations Between Individual Religiosity Client Characteristics Outcomes...45 Differences in Client Outcomes for Those Assigned to Programs...49 Changes in Intermediate Outcomes:, Experiences, Client Religiosity...51 Conclusions...56 Implications for Research Policy...59 Endnotes References Patient Characteristics Outcomes Final Report April 2011 Rockefeller Institute

4 Faith-Based Tables Figures Table 1. The Faith-Related Elements of Scale...8 Table 2. The Percentage of Certified Programs Reporting Religious Activities or Connections to Religious Institutions as Derived From Program Director Interviews....9 Table 3. Potential Interpretations of Joint Analysis of Impact of Characteristics Selected Intervening Variables...17 Table 4. Dependence On or of Any Illicit Drug or Alcohol in Past Year Among Persons Aged 12 or Older in Maryl, by Age Group Substate Region...20 Table 5A. Screening Participation of Clients in Experiment...24 Table 5B. Flow of Clients Through Experiment...25 Table 6. Sociodemographic Characteristics of Clients Interviewed at Baseline (Total number of cases = 62)...29 Table 7. Use Patterns (N = 62 unless otherwise noted)...30 Table 8. Mental Physical Health Problems (N=62)...32 Table 9. Family Relationships; Quality of Life...33 Table 10. Economic/Employment Status...34 Table 11. Legal Status...35 Table 12. Comparison of Baseline Interview Participants in Baltimore Study...36 Table 13. Childhood Religiosity Current Religious Affiliation (All Baseline Interviewees; N=62)...38 Table 14. Current Religious Practices (All Baseline Interviewees; N=62)...39 Table 15. Importance Function of Religiosity in One s Life (All Baseline Interviewees; N = 62) Table 16. Correlations Among Religious Items; Baseline Interviews; N= Table 17. Taxonomy of Individuals at Baseline in Terms of Their Religiosity...43 Table 18. Characteristics of Persons by Religiosity Taxonomy Table 19. Measures of Client Outcomes...46 Rockefeller Institute Page iv

5 Faith-Based Table 20. Correlations Between Three Dimensions of Religiosity Characteristics Outcomes of Individuals; Baseline Interviews Only (N = 62 unless otherwise noted)...47 Table 21. Changes in Variables Between Baseline Three-Month Post-Test Interviews Table 22. Differences in Received by Persons Referred to Programs...52 Table 23. Assessments of Programs...53 Table 24. Changes in Religious Faith Behavior: Observed Changes in Religiosity Indices Between Baseline And Post-Test Interviews Table 25. Correlations Between Changes in Client Religiosity Changes in Client Outcomes Between Baseline Post- Test Interviews Figure 1. Number of Faith-Related Characteristics, Listed in Tables 1 2, Among Certified Programs Studied in Baltimore City (N = 24) (Data Derived From Program Director Interviews) Figure 2. Changes in Religiosity Scores Between Baseline Post-Test Interviews (N = 37)...54 Rockefeller Institute Page v

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7 Faith-Based Executive Summary This report describes findings from an effort to implement a romized trial in Baltimore City to estimate the impacts of assigning individuals with substance abuse problems to faith-intensive or secular treatment programs. Because there are multiple hypotheses about the effects of faith-intensive programs, because such programs differ from resemble secular programs in complex ways, the study sought not only to estimate overall impacts but also discern how effects, if any, occurred. To create treatment control groups in the field experiment, the study used the considerable variation in faith-related characteristics found among certified drug treatment programs in Baltimore City. Romization occurred among consenting individuals who were required to attend treatment programs as a condition for receiving cash assistance benefits. Extensive baseline post-test interviews were conducted. Because of difficulties in finding individuals to participate in the experiment in ensuring that a large proportion of the participants actually experienced the treatment programs a critical part of the research design the experiment was stopped prematurely. Nonetheless, the data obtained from the experiment offer important insights into the substantive methodological issues involved in understing the role impact of faith-intensive service providers are thus reported here. There are many hypotheses about the impact of providing substance abuse treatments through faith-intensive, rather than secular, programs. Faith-intensive programs may offer greater staff commitment to the program s mission effort; they may have stronger connections with their communities; they may provide more holistic or individualized services; they may be more responsive to clients religiosity, which in turn may help clients connect with the programs; they may offer religious fellowship with other clients; or the programs may strengthen clients religiosity, which in turn may assist recovery. However, despite the wide range of speculations about the potential effects of faithintensive programs, virtually no research has been conducted on the relative effectiveness of faith-intensive versus secular substance abuse treatment programs. To prepare for the study of effectiveness, the research team twice surveyed substance abuse treatment program directors in Baltimore City about faith-related attributes as well as many other characteristics, including their services, staff, management. We found that publicly funded programs varied greatly in the presence or absence of many faith-related characteristics. Programs varied with respect to their connections to religious institutions; their use of expressly religious activities in treatment programs (such as prayer discussion of scripture); individualized assistance to clients seeking religious assistance or fellowship; the religiosity of staff. Rockefeller Institute Page vii

8 Faith-Based Faith-Based We also found that programs with without faith-related characteristics varied in other ways as well. Compared to secular programs, faith-intensive programs showed lower rates of staff turnover stronger connections to the community, such as greater reliance on volunteers more frequent interactions with community institutions. However, we found no evidence that faith-intensive programs offered a greater variety of services. In fact, faith-intensive programs were less likely to provide medical services to clients, including pharmaceutical drugs widely viewed as effective in managing substance addictions. In multivariate analyses of a dataset constructed from the merger of the program survey data administrative data on clients discharged from the programs, we found that program religiosity (including religious affiliations, staff religiosity, religious activities) were positively correlated with good treatment outcomes (such as longer times in treatment higher rates of completion) for clients with relatively mild substance abuse problems. However, program religiosity was negatively correlated with successful treatment outcomes for clients with more severe addictions. These preliminary findings suggested that if faith-intensive programs had a special effect on clients, those effects could operate through a variety of pathways could affect different clients in different ways. This complexity led us to develop a research design that used the variation we found in faith-related characteristics among treatment programs in a clinical trial with romized assignment of clients, but one that also included measurement of potential intervening variables in order to underst what pathways might lead to differences in outcomes. These intervening variables included information to be collected from the clients about their experiences with the treatment programs. The clinical trial was implemented in Addiction specialists were trained to screen potential clients for participation in the program, over 2,000 applicants for cash assistance were screened. However, over several months, only 62 clients were eventually determined to be eligible, agreed to participate, were interviewed at baseline. Of these, 43 were interviewed at the three-month post-test, but of these, only 32 had attended treatment programs could provide even minimal information about their treatment experiences. This drop-off in participation led us to end the study in mid However, the data collected at baseline at the post-test are still valuable in understing the target population; the role of religiosity among persons with addictions; the relationship between religiosity other individual characteristics problems; changes in religiosity over time,, with many caveats, differences in experiences outcomes between clients assigned to faith-intensive versus secular programs. Findings include: Rockefeller Institute Page viii

9 Faith-Based Faith-Based 1 Clients participating in the experiment at baseline were typically female, black, with children, unmarried (most of the unmarried had never been married). Most used multiple substances. Mental health problems, particularly depression, were widespread, a substantial minority reported chronic or major physical health problems. The vast majority were unemployed low-income; most lived alone with their children or with their family (not spouses or partners). Most also had been arrested convicted of crimes. 2 We also found that the clients were, with few exceptions, quite religious. Based on multiple questions about their religious background, beliefs, practices, we constructed four measures of individual religiosity: a) childhood religiosity; b) private beliefs practices; c) the perceived religiosity of friends relatives; d) attendance at worship services or participation in discussions of scripture. These dimensions were used to produce a taxonomy of clients with respect to their religiosity. Most clients reported high levels of religiosity in terms of private beliefs practices, but few participated in worship services or discussions. Differences in religiosity were related to race, to a lesser extent, age, education, sex. 3 Despite many studies that found correlations between individual religiosity various conditions behaviors, such as substance abuse, mental physical health, quality of life, we did not find consistent relationships between religiosity such conditions among baseline interviewees. We found, however, two exceptions. Clients whose family members friends were religious typically began abusing alcohol or drugs at later (that is, older) ages. Also, religiosity more generally (not just the religiosity of family friends ) was associated with a later (again, older) first-use of cocaine. 4 For a wide variety of client outcomes (mental health, physical health, employment, legal status, quality of life), we did not find significant differences between those assigned to faith-intensive programs versus those assigned to secular programs. The same was true for many measures of substance abuse. The only exception was a finding that clients assigned to secular programs were more likely to have seen a decline in problems with their families. 5 Similarly, we did not see significant differences in clients reporting of services received from faith-intensive secular programs. The only exception was a greater tendency for clients assigned to secular programs to get help in accessing public benefits. Rockefeller Institute Page ix

10 Faith-Based Faith-Based 6 One pathway by which faith-intensive programs might exert a distinctive effect on clients would be their effects on clients religiosity. But does client religiosity change? We found that some types of religiosity do not change much in the short run, while some types do. For all clients interviewed at the baseline post-test, we found little change in private religious beliefs practices. By contrast, clients reports of the religiosity of family friends were more likely to show changes over time, most of the changes indicated declines in family friends religiosity. Clients participation in worship services or discussions of scripture also changed in many cases. But the changes were typically toward greater participation discussion. Thus, the two types of social religiosity were more likely to change than private beliefs practices, though the changes moved in different directions. 7 The findings just described refer to any changes in religiosity, regardless of assignment to faith-intensive or secular programs. But how did the changes vary with respect to clients assignments to faith-intensive or secular programs? We found intriguing, though statistically insignificant, differences. Clients assigned to faith-intensive programs reported, on average, relative increases in the two forms of social religiosity: religiosity among friends family attendance at worship services discussions of scripture. Private religious beliefs practices showed an opposite pattern: this form of religiosity increased more among those assigned to secular agencies. Yet these differences in changes were not statistically significant. (Given the small number of persons interviewed at baseline post-test, we do not know whether the lack of statistical significance is due to weak or nonexistent underlying relationships between assignment client religiosity, or due to real relationships that our small number of cases cannot discern.) 8 Increases in individual religiosity did not necessarily result in improved client outcomes. We found that increases in individual religiosity were often associated with poorer outcomes, e.g., declines in physical health rates of employment, problems with the law, declines in quality of life. One exception to this pattern was a negative correlation between religiosity measures changes in the use of cocaine. In sum, the evidence we did manage to collect in the clinical trial did not clearly support any of the hypothesized pathways between faith-related characteristics in programs improved client outcomes. The small number of observations qualifies this conclusion. But if faith-intensive programs do exert significantly different effects on clients, these analyses suggest that the effects Rockefeller Institute Page x

11 Faith-Based may not be large may be complex (with some effects positive some negative some outcomes may not be affected at all). These findings confirm our initial assumption that it is critical to estimate not just summary effects of faith-intensive programs on client outcomes but to test alternative pathways of effects. However, testing such pathways poses challenges for implementing the study, which is challenging already given the need to romize clients in a field setting. The report discusses other methodological issues as well. The findings have policy implications. We do not have evidence to recommend exping or reducing the role of faithintensive programs in treating substance abusers. However, the widespread religiosity of clients does suggest a potential need for programs to respond to or at least accommodate religion in treatment programs. The findings also reinforce the sense that helping these clients is an enormous task. They face multiple severe problems, in thinking about how to help them it is important to recognize that variation in one service program may exert marginal effects at best. Finally, the challenges in carrying out the field experiment suggest that government agencies may want to consider targeting scarce public resources to more descriptive research regarding faith religion in social services, rather than make the enormous investments probably required to resolve the complex causal questions involved in determining the relative effectiveness of secular faith-intensive organizations Rockefeller Institute Page xi

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13 FAITH-BASED SOCIAL SERVICES APRIL 2010 Patient Characteristics Outcomes Final Report By Thomas L. Gais Amelia Arria The Public Policy Research Arm of the State University of New York 411 State Street Albany, NY (518) Introduction Although some drug treatment programs address the topic of religiosity, little research has examined how faith religiosity are embedded in service delivery, much less the extent to which religious elements affect the outcomes of drug treatment. Nor is much known about the specific mechanisms by which religious elements in programs affect treatment adherence or client outcomes. That is not to say that there is no relevant research on religion substance abuse. But other analyses have been limited to examining only some of the potential linkages between faith-intensive characteristics of treatment programs, their special capabilities attributes, their ultimate effects on client outcomes. One study, for instance, surveyed compared the responses of administrators counselors at Teen Challenge (TC) substance abuse treatment centers with persons in similar positions at non-tc centers (Sung, Richter, Shlosberg 2009). Teen Challenge is a national network of faith-intensive recovery programs, which was founded in 1957 now includes nearly 200 residential centers. The survey found large differences between the TC non-tc treatment providers regarding their views of human nature, morality, the causes of substance abuse, the role of science in addiction treatment. It also discovered important differences in the characteristics of counselors. However, this study examined only one specific type of faith-intensive program, it collected no information on clients effects. Other studies have described a wider range of treatment programs with faithintensive characteristics, including comparisons with secular programs (Smith, Bartkowski, Grettenberger 2006, ). But these studies have not investigated the effects of these differences on client experiences, participation, treatments, or outcomes. A much larger body of research has examined the relationship between individuals religiosity substance abuse. These studies have typically found that participation in religious activities, particularly frequency of attendance at religious services, is Rockefeller Institute Page 1

14 Faith-Based associated with a lower incidence of illegal drug use, alcohol intoxication, drug addiction (Chatters et al. 2008; Kendeler et al. 2003; Johnson, Tompkins, Webb 2002, 12; Center for Addiction 2001; Koenig McCullough 2001; Ellison Levin 1998; Miller 1998). These analyses could be useful in understing the effectiveness of faith-intensive treatment programs if a) the unique effectiveness of faith-intensive programs lies at least in part in their capacity to strengthen the religious beliefs or practices of persons with addictions; b) changes in religiosity lead to decreased drug use or other measures of recovery. However, neither of these two linkages is well established. Hardly any studies have explored the effects of different treatments on clients religiosity. A rare ( only partial) exception was a small clinical trial that examined the effects of a spiritual guidance intervention, an intervention that overlapped with religious practices but also included activities that might be practiced without specific religious references, such as meditation, reflection, service to others (Miller et al. 2008). Yet that study found no effects of the program on multiple measures of clients spiritual functioning. Nor have there been many studies of the question of whether increases in religious practices or strengthened beliefs have an effect on recovery from substance abuse. Nearly all the analyses of religiosity substance abuse cited above have been cross-sectional. Changes in individuals religiosity have rarely been measured, nor have changes in religiosity been compared to changes in client outcomes (such as substance abuse, mental health, physical health). In addition, it is also possible that faith-intensive substance abuse treatment programs may be more effective than secular counterparts by means of causal pathways that have little to do with changes in client religiosity. Perhaps faith-intensive programs have special ties to the community, such as local congregations, from which programs may draw additional resources through volunteers clergy help the program connect with clients families friends (Sherman 2003). Perhaps too those who work in faith-intensive programs view their efforts as missions devote more time energy to their jobs thus maintain stronger ties with clients show an interest in clients overall well-being. It is also possible that the availability of faith-intensive programs might allow religious individuals to find each other draw strength from each other in peer sessions or other group activities. Of course, there may also be ways in which faith-intensive programs are less effective than secular agencies. The Teen Challenge study found that counselors in TC centers were less educated had less professional training than counselors in other programs, that TC staff were also less likely to treat addictions with medications, which in many past studies had been found to be helpful in recovery (Sung, Richter, Shlosberg 2009; National Institute on Drug 1999). Faith-intensive Rockefeller Institute Page 2

15 Faith-Based programs may also be smaller organizations with few resources to provide client services. It is also an unresolved empirical question whether they are better connected with community institutions. To underst the relative effectiveness of faith-intensive versus secular providers of substance abuse treatment, the Rockefeller Institute of Government approached the University of Maryl College Park the University of Baltimore to begin a unique line of research into these issues. Phase I of the study conducted field research in Baltimore City in to discern the general role of faith faith-intensive programs in the city s substance abuse treatment system. Among the many things we found in this first phase was an unexpectedly wide range of faith-related characteristics among programs treating people with substance addictions. We also learned that the programs with many faith-related characteristics differed in other respects from programs with fewer faith-related characteristics. These other findings suggested the possibility of constructing a field experiment what we called Phase II of the study. In this phase, clients requiring substance abuse treatment would be romly assigned to an experimental group or a control group, subject to certain constraints. Participants in the experimental group would be assigned to faith-intensive treatment programs, while those that were selected for the control group would be assigned to secular programs. Constraints in making the assignments would include ensuring that clients would receive the appropriate modality of treatment at a site near the client s residence. In this research design, differences in client outcomes, measured in post-tests in changes between baseline post-test interviews, would provide estimates of differences in the effectiveness of these two types of programs. This report begins by providing background information from what was learned from Phase I of the study, where we developed an operational definition of faith intensity of a drug treatment program. We then describe Phase II the implementation of the experiment. Although this field experiment, designed to use variation in religious characteristics of existing programs, was eventually stopped due to problems in getting enough participants to produce interpretable results, much was learned from the attempt to put such a study into effect. We also learned a great deal about the extent dimensions of religiosity among individual clients, the relationships between religiosity other individual characteristics (including the severity of substance abuse problems other client outcomes or indicators of well-being), changes in religiosity between the baseline post-test observations, client responses to different treatment programs. All of these results require qualifications due to the problems of implementing the experiment, particularly the small number of cases. Nonetheless, these characteristics, correlations, changes suggest that some hypotheses lines of inquiry are promising, while others are less so. This report thus draws on all the data Rockefeller Institute Page 3

16 Faith-Based collected to indicate not only how the questions originally posed in the study might be studied in a future experiment, but also what theoretical issues, measurement questions, hypotheses need to be addressed in subsequent studies. Rockefeller Institute Page 4

17 Faith-Based Policy Context Significance of the Study Charitable Choice provisions were enacted in 2000 to ensure that religious organizations are able to compete on an equal footing for Federal substance abuse funding administered by the Mental Health Administration (SAMHSA), without impairing the religious character of such organizations without diminishing the religious freedom of SAMHSA beneficiaries. To help advance fair competition among providers of services whether they are public or private, secular or faith-based, the SAMHSA Charitable Choice legislation included a finding that establishing unduly rigid or uniform educational qualification for counselors other personnel in drug treatment programs may undermine the effectiveness of such programs, it prohibited discrimination against individual programs because of the religious nature of their training in drug treatment. 1 These legislative actions are premised in part on assumptions that faith-intensive drug treatment programs (including those whose management staff have religious training backgrounds instead of or in addition to traditional professional training for drug treatment) are at least as effective as secular programs that do not incorporate faith-related elements in helping individuals recover from drug alcohol problems. Yet there is little research on the many ways in which faith religion may be implicated in treatment programs, nor is there significant empirical research on the comparative effectiveness of treatment programs with faith-related characteristics those without, the circumstances under which differences in effectiveness occur, or organizational characteristics that account for differences in effectiveness (Noyes 2008; Wright 2009). The research we conducted through this project describe herein attempts to fill those research gaps,, as a result, may provide guidance for future research policy. Estimating the relative effectiveness of faith-intensive secular drug treatment programs discerning how differential effects occur, may have several possible policy implications. First, by better understing how certain types of programs benefit certain types of people, it may be possible to match client characteristics to program characteristics to improve long-term outcomes. Second, it might be possible to identify practices associated with faith-intensiveness that are associated with positive outcomes that may be transferable to secular programs (e.g., finding that stronger connections to community-based resources promote long-term abstinence). Our research sought to underst the mechanisms or pathways by which effects on client outcomes occur, assuming that any effects exist. Different pathways would have different policy implications. If clients enrolled in faith-intensive programs are more likely to strengthen their religious beliefs practices, if increased religiosity among clients produces better client Rockefeller Institute Page 5

18 Faith-Based outcomes, government options to increase the effectiveness of drug treatment programs in similar settings may be limited by constitutional, regulatory, /or programmatic constraints. If, however, faith-intensive drug treatment programs are more effective than others, not because clients strengthen their religious beliefs practices but because they experience less staff turnover as a result of high levels of staff commitment, then more attention may be paid to increasing the stability of the client-counselor relationship over the course of a treatment episode. By answering these questions, policymakers can underst what is at stake in making social service delivery systems more or less accessible to faith-affiliated or faith-involved programs. The study also has policy implications for federal, state, local oversight of human service programs. If legal issues arise from the exercise of certain religious practices within treatment programs, this study, which describes religious expressions activities in real programs, provides policymakers with important background information. Finally, by learning more about the context in which religiosity occurs in treatment programs, we can inform policymakers about the roles of individual choice neutrality in faith-related activities, which have been important criteria in federal court decisions in recent years when resolving constitutional questions about the application of the First Amendment of the Constitution to the delivery of publicly funded services. Rockefeller Institute Page 6

19 Faith-Based Background Preliminary Studies This project was launched with funding from the Pew Charitable Trusts, as part of its support for the Roundtable on Religion Welfare Policy, which was directed by The Nelson A. Rockefeller Institute of Government between The Roundtable s work covered a wide range of activities, including monitoring analyzing policy, administrative, judicial developments affecting the role of faith-intensive institutions in delivering human services. Part of its mission was to encourage research in this area, given the lack of analysis on the comparative effectiveness of faith-intensive institutions in serving people, the Institute decided to conduct some of its own research on such questions. Pew s grant supported the actual implementation of the field experiment. Additional support was provided for analyses of the data by the Office of the Assistant Secretary for Planning Evaluation of the U.S. Department of Health Human, by Duke University s Center for Theology, Spirituality, Health. The Institute eventually chose to conduct research on the comparative effectiveness of secular faith-related drug treatment programs in one major city, Baltimore, Maryl. The study was launched in late 2005 began with Phase I, which focused on understing the role of religion in state-certified drug treatment programs. In Phase I, all modalities of drug treatment were represented (i.e., residential, outpatient, inpatient, medication-assisted treatment programs such as methadone maintenance programs). Several findings emerged that informed Phase II, which was designed to estimate the comparative effectiveness of secular faith-intensive programs how those effects occur. Findings from Phase I came from extensive structured interviews with program directors of drug treatment programs in Baltimore City. A central focus of the survey of program directors was to gather information regarding faith-related elements of the drug treatment program. Table 1 lists the questions that were used to gather this information. Table 2 documents the findings from 24 Program Director Interviews conducted in Phase I. The most relevant findings from Phase I included: 1 Even among state-certified publicly funded drug treatment programs, considerable variation existed in faith-related elements (Table 1). Figure 1 shows the distribution of the number of faith-related characteristics among the 24 programs studied. The number of faith-related characteristics in programs ranged from four to Most of these faith-related elements varied along two major largely independent dimensions: institutional connections with congregations, denominations, orders, other religious institutions; expressly faith-related activities in the treatment programs, such as prayer, scriptural reading study, conversations about God faith, discussions with or referrals to clergy. Rockefeller Institute Page 7

20 Faith-Based Table 1. The Faith-Related Elements of Scale 1. a Does a religious institution manage or own this program? (YES, NO) 2. a Was a religious institution involved in the origin of this program? (YES, NO) 3. a Is this program in any way affiliated with a religious organization in other ways not including management, owning or the program s origin? (YES, NO) Do any of the board members have clerical backgrounds or are any of the members affiliated with religious institutions or 4. organizations? (YES, NO) In the course of providing services, how often do the following occur: singing of hymns or other religious songs, or performing 5. a music in other ways as a form of worship? (NEVER, RARELY, SOMETIMES, OFTEN) 6. b Does the program s mission statement suggest that religious beliefs play a part in providing services at this program? (YES, NO) 7. b Does your program attempt to help clients strengthen their own religious faith practices? (YES, NO) To what extent does this program emphasize prayer or other religious activities as a type of counseling or therapy? (NOT AT 8. ALL, NOT MUCH, SOMEWHAT, GREAT EXTENT, VERY GREAT EXTENT) How important is it to this program s philosophy to make certain that substance abuse clients are provided with appropriate 9. b assistance in addressing spiritual or religious problems or concerns? (NOT AT ALL, NOT MUCH, SOMEWHAT, GREAT EXTENT, VERY GREAT EXTENT) For staff in this program, are their religious beliefs practices of central importance to their lives, so far as you can tell? 10. (FOR MOST, FOR A SIGNIFICANT NUMBER, FOR A SMALL NUMBER, FOR ONLY A FEW OR MORE) 11. b In the course of providing services, how often does prayer occur? (NEVER, RARELY, SOMETIMES, OFTEN) 12. b In the course of providing services, how often do conversations about God beliefs about God occur? (NEVER, RARELY, SOMETIMES, OFTEN) 13. b In the course of providing services, how often do the following occur: bible study or other readings discussions of scripture? (NEVER, RARELY, SOMETIMES, OFTEN) 14. b In the course of providing services, how often are clients referred to clergy? (NEVER, RARELY, SOMETIMES, OFTEN) 15. b In the course of providing services, how often are clients encouraged to attend church or participate in other opportunities for religious fellowship? (NEVER, RARELY, SOMETIMES, OFTEN) In the course of providing services, how often do conversations about spiritual needs of individuals, with little reference to 16. specific religions, occur? (NEVER, RARELY, SOMETIMES, OFTEN) Does this program have separate service tracks, regularly scheduled lectures/groups, or programming offered as needed for 17. individuals with strong religious beliefs? (NO, REGULARLY SCHEDULED LECTURES/GROUPS, OFFERED AS NEEDED, SEPARATE TRACK) 18. a Has the director previously worked in religious institution or faith-intensive organization? (YES, NO) Scoring Directions: Possible responses are shown in parentheses following the item. A score is derived by summing the number of bolded responses. Factor Scores: The results of the factor analyses from data collected during Phase 1 yielded two distinct factors: a) Institutional Connections Factor that was derived from four items relating to religiosity of the management, operations staffing of the program interestingly, songs loaded onto this factor. These items are indicated with a superscript a next to the item number. b) Programmatic Activities Factor derived from ten items relating to programmatic activities. These items are indicated with a superscript b. 3 Programs also varied according to the religiosity of their staff. This dimension was moderately correlated with both faith-related dimensions. 4 Differences in religiosity among programs were related to other differences in programs, according to additional data gathered as part of the program director interviews. For instance: a b Both dimensions of religiosity were positively correlated with lower levels of staff turnover. Staff turnover was particularly low among programs with highly religious staff. 2 Program leaders in agencies that had strong institutional connections were more widely involved Rockefeller Institute Page 8

21 Faith-Based Table 2. The Percentage of Certified Programs Reporting Religious Activities or Connections to Religious Institutions as Derived From Program Director Interviews Item on the Faith-related Elements of Scale (ordered by frequency of positive response) % In the course of providing services, how often do conversations about spiritual needs of individuals with little reference to specific religions, occur? 92% In the course of providing services, how often are clients encouraged to attend church or participate in other opportunities for religious fellowship? 83% How important is it to this program s philosophy to make certain that substance abuse clients are provided with appropriate assistance in addressing spiritual or religious problems or concerns? 79% For staff in this program, are their religious beliefs practices of central importance to their lives, so far as you can tell? 71% Does your program attempt to help clients strengthen their own religious faith practices? 71% In the course of providing services, how often do conversations about God beliefs about God occur? 71% In the course of providing services, how often does prayer occur? 54% To what extent does this program emphasize prayer or other religious activities as a type of counseling or therapy? 46% Do any of the board members have clerical backgrounds or are any of the members affiliated with religious institutions or organizations? 46% In the course of providing services, how often do the following occur: bible study or other readings discussions of scripture? 42% Is this program in any way affiliated with a religious organization in other ways not including management, owning or the program s origin? 38% Has the director previously worked in religious institution or faith-intensive organization? 33% In the course of providing services, how often are clients referred to clergy? 29% Was a religious institution involved in the origin of this program? 25% Does this program have separate service tracks, regularly scheduled lectures/groups, or programming offered as needed for individuals with strong religious beliefs? 21% Does a religious institution manage or own this program? 12% In the course of providing services, how often do the following occur: singing of hymns or other religious songs, or performing music in other ways as a form of worship? 8% Does the program s mission statement suggest that religious beliefs play a part in providing services at this program? 8% in the community the programs relied more heavily on volunteers. 5 Despite these differences between programs of different institutional affiliations faith-related activities in their operations, turnover, services, the goals of programs did not differ much between programs of different levels of religiosity. faith-intensive programs reported similar priorities, including abstinence from drugs or alcohol, law-abidingness, stable employment, living independently. The findings from Phase I demonstrated that variation in faith-related characteristics was extensive among publicly funded programs in the city, that there were reasons to believe that the variation may affect program operations, capacity, client experiences which in turn may affect client outcomes. Rockefeller Institute Page 9

22 Faith-Based Figure 1. Number of Faith-Related Characteristics, Listed in Tables 1 2, Among Certified Programs Studied in Baltimore City (N=24) (Data Derived From Program Director Interviews) To ensure we had good information on the programs, on as many as possible, we shortened our original interview of program directors (which was conducted in 2006) readministered the survey in late 2007 early We surveyed 36 programs in this second round (out of 40 programs determined to be appropriate, for a response rate of 90 percent). For the most part, we found there was agreement in faith-related answers for programs interviewed in both rounds, though some shifts occurred. Some treatment programs, particularly some of the faith-intensive programs, no longer existed. Still, we again found considerable variation in faith-related characteristics, these newer data were used to identify programs high ( low) in faith intensity. The second survey of program directors uncovered more complex dimensions of religiosity. The three major religious dimensions were: 1 Program Religiosity: This was a broad construct composed of three correlated yet conceptually distinct sub-dimensions: a b c d Institutional connections: Organizations high on these variables have ties or affiliations with congregations or religious denominations, either in the past or in the present. Expressly religious activities: Organizations high in this subcategory of variables incorporate some combination of prayer, scriptural study, religious singing in their treatment activities. Staff religiosity: Some programs report having a staff for whom religious belief practices are central to their lives who express their religiosity freely at work. We averaged these three subcategories of variables (with equal weights given to each of the subcategories) to create the overall program religiosity variable. 2 Individualized Assistance: We created an index measuring the degree to which programs assist individual clients in Rockefeller Institute Page 10

23 Faith-Based finding congregations or getting other forms of religious or spiritual assistance, typically outside of the program itself. That is, religious treatment responds to individuals needs rather than being a group activity or general activity of the program. 3 Religiosity of Clients: Some closely correlated items indicated whether or not clients talked about God or used religious terms in discussing problems. Although this is in part a client characteristic, we also viewed it as an organizational characteristic, as it reflects a program s openness to discussions about the religious views feelings of individuals. We used these three indices in a multivariate analysis of the administrative data on clients to estimate the effects of faith- intensive program characteristics on client outcomes; this analysis is discussed below. The indices were also used to structure the experimental phase of the study. We used the scores produced by the second survey to identify programs that provided the same modality of treatment served a similar geographic area but that differed considerably in the roles of religion in their operations. Faith-intensive programs were defined as those that scored very high (within the top quintile) in one of the three subcategories under program religiosity, i.e., institutional connections, expressly religious activities, or staff religiosity. They also included programs that were very high in the overall program religiosity score but not very high on any one of the subcategories. programs were defined as those that scored very low on all forms of program religiosity. However, in some parts of the city where we were conducting the field experiment, we needed more programs to ensure that enough openings would be available for assignment of clients to different programs. Thus, where we did not have faith-intensive secular programs providing treatments of similar modality to a similar geographic area according to the criteria described above, we exped the definition of faith-intensive programs to include programs that were moderate on the program religiosity scale high on one of the other two main indices (individualized assistance client religiosity). In the end, we had good contrasts between programs offering comparable services in all areas. However, it is also true that what constituted a faith-intensive program varied across localities. We decided to deal with that problem by collecting information about potential intervening or moderating factors that might account for the differences an important aspect of the research design discussed below. Rockefeller Institute Page 11

24 Faith-Based Hypotheses The purpose of Phase II of the project was to underst whether how religiosity in drug treatment programs increases, decreases, or has no impact on the effectiveness of such programs in treating patients with substance abuse problems. Programs faith-related characteristics were hypothesized to influence the effectiveness of drug treatment programs in several ways. One line of thinking suggests that faith-intensive organizations may be more effective because of they are more effective service providers. These effects may occur regardless of the religiosity of particular clients. For instance, faith-intensive programs may be more effective than others due to: 1 Staff commitment: A staff for whom religion is important, expressed, shared may be one that is more committed to the treatment program its mission. This commitment may lead to less staff turnover stronger relations with patients. Commitment low turnover may also lead to greater agreement about the program s mission within the organization, a factor that may also enhance organizational effectiveness. 2 Connections with community: Religiously affiliated programs may have stronger ties with their communities, which may in turn increase their effectiveness by giving them better access to a wide variety of services, promoting a better understing of client problems challenges, improving knowledge of client families friends, facilitating participation of clients in local congregations. 3 Holistic or individualized services: Although it is unclear whether a more holistic treatment of clients treating a wide range of client problems, keyed to the specific needs of each client is an effect or cause of program religiosity, the first phase of the research did find that certain types of faith-intensive groups were more holistic in their treatment programs than others. A second set of hypotheses involves assertions that faith-intensive characteristics in programs may aid in recovery by responding to or promoting religiosity among clients. That is, faith-intensive programs may aid recovery by: 4 Responding to clients religiosity: Faith-intensive programs may be more effective to the extent that they respond to clients pre-existing religiosity by using or at least accepting religious terms in talking about problems of addiction struggles with recovery, by facilitating religious fellowship between clients others with similar faith, by being open to religious practices, such as prayer. This individualized responsiveness may strengthen religious practices or involvement in a religious community, which Rockefeller Institute Page 12

25 Faith-Based in turn may promote recovery. One version of this hypothesis may involve responsiveness to clients dormant religious backgrounds. For example, we found some programs used readings of Biblical stories to begin discussions with groups of clients about their own struggles, since such stories were typically well known to most patients, religious or not, since it was possible to find scriptural stories that raised many of the fundamental problems with which patients were dealing. Widespread religious upbringing among clients may also cause certain helpful symbols or concepts to resonate deeply with clients, such as the idea that we are all children of God. 5 Creating a shared religiosity between patients staff, or among patients (if peer-to-peer sessions are used): If religiosity is shared between patients staff, they may form stronger bonds; patients may feel more comfortable in their interactions with staff; patients may be more likely to attend treatment longer, increasing the effectiveness of treatment. Also, if most patients within a program share religious views, peer-to-peer interactions may be stronger more comfortable for patients, also possibly increasing the probability of treatment retention completion, conditions that typically lead to better outcomes. For instance, a study of mutual-aid groups in recovery programs found that individuals whose religious beliefs matched those of other group members were more likely to participate in such programs (Atkins Hawdon 2007; for more on peer effects, see Buchanan Latkin 2008). 6 Religious conversion or transformation: Patients in programs that encourage strengthening of client religiosity, or that respond readily to client expressions of interest in a more religious experience, may intensify their religious beliefs practices, including their participation in local congregations their sense of belonging in a religious community. In turn, these changes may lead to better client outcomes. Some forms of religiosity are negatively related to substance abuse (see, for example Miller 1998; Stark Bainbridge 1997; CASA 2001). Some forms of religiosity have been found to lead to greater use of treatment programs (Harris, Edlund, Larson 2006), which in turn may lead to better outcomes. Such changes may occur among participants regardless of their prior religiosity, though it is also possible that such conversions are more likely to occur among persons raised in a religious household or who have some other predisposition to respond positively to faith-related activities settings. In any event, prior studies, like many other analyses that have found statistical associations between religiosity health, have not resolved questions of causation, nor have they clarified the mechanisms by which religion participation in religious communities affect Rockefeller Institute Page 13