Home » Outcomes » Research Evaluation of ARRIVE - Final Rpt.
Research Evaluation of Exponent’s ARRIVE Program
May 4th, 2009
Ricardo Barreras, PhD
Ernest Drucker, PhD
- Overview -
Exponents operates as a set of nonresidential treatment and relapse prevention programs with 20 years of continuous experience helping New Yorkers struggling with addiction and HIV/ AIDS. The programs at Exponents are all voluntary but do require a substantial personal commitment by the client. The approach is founded on a set of core principles: meeting substance abusers “where they’re at”, utilizing peer models for support and therapeutic objectives, and creating a non-judgmental healing environment. The program rejects coercive methods, humiliation, harsh sanctions, intimidation, moralization, and punishment. As it helps to get clients current drug use under control or helps clients stay drug free, the program addresses the clients decades of emotional and personal trauma - often with long histories of criminal justice involvement - that keeps them locked into a cycle of drug use and addiction. These goals and models of intervention are the framework for Exponents most important program, ARRIVE, a 14 week psycho-educational program where clients spend three full days each week in a series of intensive classes, counseling, and group sessions. This report describes an evaluation framework we have created for considering ARRIVE’s methods and assessing some of its client outcomes.
ARRIVE works from an evidence based model for the sustained therapeutic engagement of people living with HIV/AIDS. Current and former drug users (most of whom are also living with HIV/AIDS) are offered a consistent and disciplined model of practice. This takes place within a carefully designed environment that enables the programs therapeutic and social goals. Every aspect of the program, from the topics covered in classes and the individual and group counseling work, to the selection, training, and supervision of staff, and the atmosphere of the facility, has been purposefully designed to foster a sense of openness, acceptance, and respect for self and others. This approach often runs counter to the traditional therapeutic community (TC) models of drug treatment– which both require total drug abstinence as a condition for program participation and punish drug use through loss of privileges and other sanctions – including expulsion from the program. The highly regimented and sanction-based philosophy of traditional TCs is reinforced by the fact that such programs are often mandated by the criminal justice system as an alternative to incarceration. By contrast medically assisted treatment programs (e.g. with Methadone or Buprenorphine) provide useful pharmacological supports (especially for opiate users) and some counseling services , but they seldom engage the psychological and social dimensions of the client’s life – which after years of drug use and addiction (and criminal justice system involvement) is often in disarray and full of unresolved personal and family issue that remain an obstacle to full recovery and successful adaptation to family and community life.
Instead the approach of Exponents/ ARRIVE represents a “Third Way”, that incorporates elements of TC programs and evidence- based and/or medically assisted and psychotherapeutic program models. ARRIVE’s program philosophy has deep psychological roots that address the feelings of despair, rage, and shame which result not only from addiction and criminal justice involvement, but also from being branded with the stigma of HIV and AIDS. Exponents recognizes that, for many people, living a drug free life (or even reducing or their managing drug) use can not be achieved without addressing their damaged sense of self and getting clients to understand how they have been affected by their drug use and HIV status. This report is an effort to capture these principles and practices and to better understand how clients react to them.
Scope of Study
The overall goal of this study was to collect and analyze data that describes the ARRIVE program in detail and uses these data to develop and apply an evidence based framework to assess the programs methods and its impact on the clients – especially on their emotional lives and their understanding of the relationship between their past lives and their future aspirations. Within this set of goals, the more specific objectives of the research were determined collaboratively in a series of meetings and individual interviews conducted with Exponent’s leadership and staff.
But there are some constants : all programs need to know who their clients are, to have a well-articulated set of principles, to have an understanding of the how well these principles actually make their way into practice, to recognize clients responses to and attitudes towards the program, and to gauge its impact on their behavior and other client outcomes. The specific objectives of this report therefore include the collection of data on the major topics and dimensions of the program: i.e. The characteristics of the population that attends ARRIVE - including their histories of drug use, prior experiences with drug treatment; client’s personal struggles with shame, stigma, and HIV/AIDS, and criminal justice involvement. This also includes data collection on staffs understanding of the programs underlying philosophy and core principles; and how its methods and practices reflect program philosophy; how staff are selected trained and supervised; perceive their experiences in the program; and the extent and manner in which clients are affected by ARRIVE- i.e. if and how they benefit from their involvement with ARRIVE – including changes in patterns of drug use and rates of completion and graduation from the program. A constant theme was to see if clients in the ARRIVE program are better able to manage their HIV/AIDS and their drug use or to abstain from drugs altogether, to live in more healthy ways and become better able to deal with their HIV status, and to work more effectively towards their other goals in life.
The data collected to meet these objectives and their interpretation constitute the main findings of this research. While these may be seen as a contribution in their own right, they can also serve as the foundation for a larger-scale and longer term program of research at Exponents – where more can be learned from a larger sample size and longer-term client follow up than was possible in this preliminary study.
Study Goals
Three areas of investigation and related research questions were developed based on the initial series of interviews and focus groups with staff:
1-Population Served: What are the characteristics of ARRIVE clients? What types of individuals choose to receive services from ARRIVE and what are their goals in coming to ARRIVE? The goal here is to understand the types of individuals that choose to seek services from ARRIVE, their social and personal backgrounds, and their reasons for coming to ARRIVE and their personal goals and expectations from the program.
2-Core Principles and Implementation of ARRIVEs therapeutic model:What is the program’s underlying philosophy and what are its core principles; how are these principles translated into practice? The goal here is to develop a conceptual language that accurately describes and clearly articulates ARRIVE’s model and methods – employing the concepts of ARRIVE’s therapeutic program model as a basis of its educational program, its drug treatment philosophy, and the nature of its educational services. We sought to describe and document the programs various methods as they are employed with clients and to describe the clients responses to and attitudes about them
3-Program Impact and Outcomes: How do clients respond to this model , do they perceive any benefits that they get from their involvement in the program, and what are these? The goal here is to identify and measure the results of several important outcome variables in the areas of HIV and personal health: i.e. patterns of drug use, and changes in self concept, personal awareness, and social adaptation- as evidence of ARRIVE's effectiveness in influencing these outcomes.
- Methods -
This research was conducted over a four-month period from Nov 2008 – Feb 2009, utilizing both qualitative and quantitative methods organized in three stages.
Stage One: The first stage of the research was to collect extensive qualitative data from staff and clients. Given the complexity of the issues under investigation, such data are essential to getting a richer and more accurate description of the program as experienced by the clients and staff. For example, how do clients experience the program? What do they say about how they may benefit from it or about any negative experiences? Do they feel it is different from other programs, and if so how? How does staff think about the programs core principles of the program, and how well are they actually able to articulate these principles? How do they address issues of shame, stigma, and despair? More broadly, how are various values, mindsets, and worldviews (including but not limited to attitudes about staff’s own personal histories of drug use and HIV/AIDS) converge to determine the effects of the program model and services offered at ARRIVE?
This type of information needs to be understood through the analysis of discourse and narratives – it cannot be adequately captured through statistics or coded categories. Therefore, we conducted focus groups and interviews with all staff who have a role in the therapeutic process, as well as with current and former clients. Staff were asked to describe the nature of their work (their day to day activities), what they felt were the underlying principles of ARRIVE and how this translated specifically to how they work with clients, and were asked to give several examples that exemplified how they do their work. They were also asked about any challenges they faced in their work and if the felt ARRIVE was different than other programs - and if so, how. Clients were first asked very generally how they felt about the program, their experience, both positive and negative, and if they had benefited in any way. They were also asked to contrast their experience at ARRIVE to their experience in other programs.
Stage Two: The second stage of the research was extracting and collating descriptive data on the population’s characteristics from one cycle – a single class of 77 ARRIVE clients[1] – who were enrolled just prior to the onset of the study (in Sept 2008) and who formed the base population. We relied on intake data collected by ARRIVE and entered into their case management data system. In addition to the data already entered and stored in ARRIVE’s client database, we collected client data stored in paper form, but not entered in their database, but was relevant for the research. We did this for roughly 75% of the 102nd cycle (n = 56). Therefore, in the SPSS database developed for this research, there was descriptive data (demographics, HIV/AIDS, housing, SES, past drug treatment attendance) on all 77 clients, which came from ARRIVE’s existing client database, and additional data on drug use, criminal justice involvement, risk behavior, and HIV drug adherence on a third of the for a 75% of the sample, which came from client files.
Stage Three: The third phase of the research was designed to collect data on clients after they completed the program. Follow up interviews of a random sample of clients who graduated were conducted on a third of the sample (n=27, 35% of the 102nd cycle). These were all clients who completed the program. They were interviewed via the phone or in person at Exponents offices two to four weeks after completing the program). Clients were asked about the reasons why they chose to attend ARRIVE, their history of drug treatment, and questions about their past drug use (assessing the severity of past use, feelings of shame and stigma) and of current drug use (had it changed since attending ARRIVE- e.g. if they still use, do they use less frequently or in less risky ways?). We also asked them if they had a better understanding of their own drug use since coming to ARRIVE. Similarly we asked about HIV, how well they were able to deal with it in the past and if this had changed since attending ARRIVE. Finally, we asked a more general question about where any other aspect of their lives had changed since attending ARRIVE, such as family relationships, how they feel or think about themselves, and about any changes in their employment or educational goals.
- Findings -
Objective 1 –Detailed Description of the ARRIVE Population
The first objective (as in most program evaluations) is to begin with a comprehensive description of the client population. This data is necessary in order to be able to generalize the findings of this study to other populations seen in other programs, to determine how different types of clients respond to the ARRIVE model, and to identify the types of individuals who are retained for the full 12 weeks and benefit most from the program.
Data was collected on the populations demographic make up (age, gender, race /ethnicity, sexual orientation); history ofcriminal justicesystem involvement; health and social history (including HIV status and utilization of related services), drug use, housing/homelessness history); and prior treatment experience: (particular attention to drug treatment history, including the number of and types of prior treatment programs, retention/completion at previous programs, and qualitative data on prior drug treatment experience).
Demographic Profile
Table 1 provides demographic data on clients. The ARRIVE clients are similar to those of other drug and AIDS programs in the NYC area - they are largely people of color (86% are Black or Latino) and are middle aged or older (median age is 43; 70% are 40 years of age or older). These are mostly individuals with a long history of drug use and many are individuals that have been struggling with HIV/AIDS for many years.
Table 1: Sample Characteristics
Age
Gender
Sexual Orientation
Race/Ethnicity
Mean (range)
Male
Female
Heterosexual
Gay/Lesbian
Black
Hispanic
White
Other
43 (18-89)
48%
51%
77%
23%
30%
56%
?
1%
Most of the cycle, but not all, represents the economically marginalized segment of society. Roughly a third (31%) have less than a high school education (37% have a high school degree or a GED); only 10% are employed full time (68% are unemployed, and 22% are in school or some form of training); and 38% are in some form of housing other than renting or owning their own residence (23% in a shelter, homeless or in a transitional home, 14% in a drug treatment facility, and 1% in a psychiatric facility). However, it’s important to point out that 62% do have stable housing and a third are either working or in school or training, so there is diversity with regard to conventional SES indicators.
Table 2: SES Indicators
Education
Employed
Housing
Less than HS Diploma
Full/par time/
School/
Training
Unemployed
Rents/Lives
With Family or Friends
Shelter/
Homeless/
Transitional
Drug Treatment Facility
Psych.
Facility
31%
10%
22%%
68%
62%
23%
14%
1%
However, there are important differences in this population as well, and these differences may speak to the ability of ARRIVE to attract a diverse range of individuals. Half are women and (25%) of all clients identify as gay or lesbian – a profile that differs from that seen in most TC programs in NYC. This supports the notion that ARRIVEs non judgmental approach may be successful at attracting a wider range of clients that do not necessarily fit well into traditional drug treatment programs. Most other treatment programs do not create such heterogeneous populations and tend to be skewed towards a single gender, be largely heterosexual, or tailored specifically for gay and lesbian clients (many women feel more comfortable with all women programs and many gay and lesbian clients seek programs that that are for gay/lesbian individuals
Drug Use and HIV/AIDS
Table 2 provides data on client drug use, past drug treatment history, and criminal justice involvement.
Drug use: Current drug use is not the central feature for most of this group- but as with the social and demographic profile, the population’s drug use status is very diverse. 22% reported no history of drug use at all, and roughly half of the sample (53%) had ceased using drugs for six months or longer (range: 6 months to several years). However, for a quarter of the sample, drug use was an issue that they were currently struggling with (15% reporting drug use 90 days prior to admission and 10% reporting drug use six months prior) .
Table 3: Drug Use, HIV/AIDS, & Criminal Justice Involvement
Drug Use & Treatment
HIV/AIDS
Criminal Justice Involvement
No history of Drug use
Past 90 Day Use
Past 6
Month Use
No Use, 6+ Months
Prior Drug Treatment
HIV +
Ever
Arrested
Ever Incarcerated
Currently On Parole
22%
15%
10%
53%
70%
70%
68%
48%
10%
HIV and AIDS: Of the entire group 65% are HIV positive. Drug use and AIDS are closely related: 74 % of those with HIV were also drug users
Criminal Justice History: Over two thirds (68%) of the ARRIVE sample has been arrested, and roughly half (54%) have spent time in jail or prison (range: 3 months – 15 years, avg.: 3.8 years) and 10% are currently on parole or probation.
Reasons for seeking services at ARRIVE
The follow up interviews provide some insight into what clients seek help with when they come to ARRIVE where clients were first asked “what are the reasons you chose to come to ARRIVE?” Figure 1 shows the reasons why people come to a ARRIVE. We see that 17% (2 out of 12) mentioned information and support for drug use/addiction as the only reason. Another 25% mentioned help with both drug use/addiction and HIV/AIDS. Therefore, around 40% of ARRIVE clients are seeking help with their drug use or addiction. A third of clients come solely for support and information regarding HIV/AIDS. Then there are a quarter of clients that specifically said they were there for employment reasons, and each mentioned getting an ARRIVE certificate as step towards CASAC certification and employment in the drug field. It’s important to note that among this group, they also mentioned wanting more knowledge about HIV/AIDS and drug use.
Figure 1: Primary Services Clients were Sought from ARRIVE
Summary of Client Characteristics
One third come because of HIV/AIDS , and 25 % each for employment and combinations of AIDS and drug use ; 17% for help with preparation for employment – including work in peer counseling. Staff perceptions about why people come to ARRIVE seem to coincide well with why the clients say they come to ARRIVE. One counselor said, “60% to 70% come because they’re positive. The main thing is information.( about HIV) ”, While it is true that about 70% of clients are HIV positive, and do seek information
.( about HIV) ”, While it is true that about 70% of clients are HIV positive, and do seek information, many of those also have a history of drug use, and a quarter mentioned help with addiction as either the only reason (16%) or one of the reasons they went to ARRIVE.
These data
also speak to the diversity of ARRIVE clients. As one counselor mentioned, “not all people are bottom level people.” And another counselor said “not everyone is in recovery. Some people had prior drug problems, but had not used in a while.” This speaks to the specific role that ARRIVE may play for some more stable clients as a type of after care, used for relapse prevention for those now largely abstinent, but still at some risk for relapse and concerned about that. As one client described his abstinence and current relationship with drugs, “even when I’m not using, it’s on my mind.” This client had been abstinent for over a year, but still said he benefited greatly from ARRIVE in terms of understanding his own drug use much better.
Finally, there is the group of clients (a quarter in this sample) that were quite clear that they were there for employment reasons. Each mentioned the ARRIVE certificate as something they wanted to obtain. As one counselor mentioned, “the certificate is a big deal.” They clients tended to be highly motivated and highly functioning. In the last section of this report, we discuss the potential role that these client may play in diseminating ARRIVE’s THR approach as they gain employment in the field.
Objective 2 – Documenting ARRIVE’s Therapeutic Model: The Third Way
The second objective is to define and document the core principles that underlie the ARRIVE treatment model. All of the focus groups and interviews we conducted sought to identify both the philosophy underlying ARRIVE’s therapeutic approach and to learn how these principles are translated into practice in the program. Using material from our meetings and interviews with staff and clients, we developed a concise statement of core principles that lays out the philosophy underlying this public health model (called the “Third Way” because it has some elements of TCs and some elements of medically based treatment models – as well as traditional individual and group psychotherapeutic models and (more recently) harm reduction psychotherapy programs (e.g. the work of Andrew Tatarsky).
Core Principles
We extracted three core principles for the conduct of ARRIVE’s program. These are based on Exponents documents and on the interviews and meetings we had with program management, staff, and clients – this model has been in place since 1987. These core principles include:
1) Compassionate, non-judgmental, approach: This is bases in open and non-coercive staff attitudes and practices, including the “destigmatization” of ones personal narrative and social biography – which also forms the basis of staff selection, training , practice, case supervision, and program and staff evaluation;
2) Client-centered, strength-based approach: This is a holistic approach to drug use and its treatment and relapse prevention. It’s based on a commitment to wellness management with an important role for the personal life experience of staff, many of whom are themselves HIV affected and/or former drug users and prisoners. A sense of personal empowerment is fostered through the use of positive role models, advocacy and active political engagement for issues important to clients (e.g., participation in the successful efforts for Rockefeller drug laws reform)
3) Public health approach to drug use and living with HIV/AIDS: The third principle is the reliance on evidence-based models of prevention (primary and secondary) incorporating proven therapeutic community principles and practices (e.g. peer leadership, community building, and a strong self-help orientation) with a structured psycho- educational program that explores the roots of addiction, depression, and self destructive behaviors.
The expression of these principles in the ARRIVE program and staff practices are illustrated and supported below, with examples and narratives from interviews and other data collection.
A Compassionate, non-judgmental approach – When asked to describe ARRIVE’s model, the single most common response (from both staff and clients) had to do with its being compassionate and non-judgmental. This core principle lays the foundation for much of ARRIVE’S approach, its social and professional atmosphere, and the design of its clinical and educational interventions. The approach is framed as a way to deal with the often profound sense of stigma, shame, and mistrust many clients come in with, and which may be a result of their prior involvement in drug treatment, prison, and HIV and welfare systems. To address and reverse many of the harms of prior “treatment” (so often linked to punishment) this goal must be transferred into practice by creating an atmosphere of respect, fostering dignity, and rewarding openness and honesty.
“Peoples attitudes here, they’re open, I can relate to them”
“I feel like I fit in this place” …..
“Our goal is to ease stigma, the stigma of incarceration, of drug use, and HIV and to
cope with the isolation of people being on the fringe of society. The goal is to normalize.”
One of the themes that was repeated consistently, and reflects the response to this principle was the presence and importance of an atmosphere of “Love” and “Acceptance.” Both clients and staff (many of whom are former drug users and /or people living with HIV/AIDS) perceived this to be crucial throughout their experience in ARRIVE. As one staff member said, “What other drug programs have their Director dealing with clients at such a personal level,” and talked about how the Director, Howard Josepher, is a presence in many of the classes and activities and often hugs clients. Howard is constantly interacting with them, and conducts one of the main ARRIVE sessions. The program has a very clear non-hierarchical aspect to it, as many clients and staff noticed and remarked upon, and the fact that Howard is around, and available, is consistent with
this principle. The clients also have a voice in the program and have many chances to comment on what they like and don’t like during mid-term evaluations, where the Director takes time to read
each client's comments and address them personally.
Many clients interviewed talked about how other programs they’ve been involved in lack this human, accepting component characteristic of ARRIVE. In stark contrast, they often portrayed other programs as alienating, stigmatizing, and as disrespectful. One client complained at length of how he’s been treated at other programs. He was referring specifically to drug-free housing programs he attended in the past (because he recently lost his apartment): “they talk down to you, they deal with you through punishment, booking you or taking a pass when you mess up.” Here they embrace you, build you up, not tear you down.” Another client voiced a similar experience, “They think they’re better than you. People here need treatment, not to be attacked.” Referring to his other drug treatment programs, the client mentioned above talked about the differences between Arrive and NA and AA. “People are not close, not personal. I don’t count there. I don’t fit in.”
One fixed requirement of ARRIVE is regular attendance. When asked if it was difficult to not miss three sessions (according to program requirements), clients unanimously said “no, not at all.” The said they enjoyed coming to ARRIVE, that it was a not at all a burden. One client said, “It’s a pleasant experience coming here. This is the light of my day.” It is noteworthy that the halls are filled with art work, and the color scheme is bright but restful – one rarely hears a raised voice at ARRIVE.
Client Centered, Strength-Based Approach: A compassionate, non-judgmental atmosphere makes it much easier to address the core issues clients are struggling with. ARRIVE’s method of doing this is grounded in client-centered, strength based approach. It shares the goals of many treatment/support programs, mainly taking responsibility for one’s life and learning how to make the healthy decisions, but does so in a more holistic, supportive, manner. Management often talks about an “Eastern” influence and use terms like “mindfulness,” and “being conscious and aware of oneself and one’s decisions.” Much of this process is geared towards relapse prevention (for those with histories of drug addiction) and learning how to live better with one’s HIV status (for those who are positive), and utilized concepts grounded in traditional psycho-education.
“If you don’t deal with affect early on, you can’t deal with content.”
“We help them take responsibility for their choices, not to operate from a victim mentality.”
It’s important to highlight the fact that the compassionate, non-judgmental approach is not an ideological decision, but is based on a clinical model. Staff recognize that one of the greatest obstacles to recovery and to dealing with the issues that clients come in with is the “tremendous amount of emotional baggage that clients bring.” Terms like shame and stigma were brought up consistently. As one staff said, “We deal with affect early on, we try to foster openness. If you don’t deal with affect early on, you can’t deal with content.” Dealing with things like shame, stigma, anger is an end in itself and a means of being able to address other issues, such as drug use and AIDS
Taking responsibility, mindfulness, relationship with oneself: Taking responsibility can mean many different things. It may mean sobriety, it may and often means making your own choices. “We help them take responsibility for their choices, not to operate from a victim mentality.” They try to let them see that living in the past and having an antagonistic relationship with oneself is self-destructive. Much of this involves discussions about making choices, and about having a better
relationship with oneself, making the choices in the here and now. Discussion about this approach brings up terms like “raise awareness,” “consciousness,” “changing sense of self,” “not reacting, but thinking.” Their goal is to have “clients become experts in their own experience.” Much of this reflects the Eastern concept of “mindfulness.”
Dealing with Anger: Many clients come in with serious anger issues – usually because of how they’ve been treated in the past and histories abuse- and because of feelings about their HIV status. Staff recognize the importance of tolerance, and of how to intervene in ways that don’t further estrange or marginalize clients, while at the same time addressing inappropriate behavior. Any unacceptable client behavior is not punished but rather addressed in a didactic manner , with clients who are helped to get at the source of this behavior.
Meditation and stress management - Many elements of the program borrow from Eastern philosophies and meditative practices. This is reflected in the physical environment of ARRIVE e.g. the use of temple bells to define time periods of the program , the restful colors of walls , and in the social atmosphere of the spaces used for meetings - signs with basic statements of a contemplative philosophy ( rather than announcements of written rules) a generally quiet civil tone , no yelling, and the use of music. In some programs - meditation and acupuncture are available.
Advocacy and Empowerment: “We fight for our clients, and when they see this, it means something to them.” Advocacy is meant to have a transformative effect on client: “We take on this issues that impact our client population” Engagement in struggles over social policy (e.g., Drop the Rock demos). “They (clients) buy into the system when they think they can have an effect” Transformative is also a term that may be valuable here to describe the role of advocacy. Important to note that there was some disagreement about how core advocacy is and a recognition that it’s not as present as it was in the past.
Public Health approach to drug treatment:The approach to having clients live drug free, reduce their drug use, or use drugs in a less harmful manner incorporates evidence-based, public health principals. Most importantly, abstinence is not required to participate in the program and clients are not punished for use. In other words, there’s a low threshold for receiving treatment and support.
The third principle is the reliance on evidence-based models for treating drug use and helping clients living with HIV/AIDS. This includes stabilization of the client’s life to support effective HIV treatment and programs for relapse prevention. ARRIVES model incorporates proven therapeutic community principles and practices (e.g. peer leadership, community building, and a strong self-help orientation) and a structured psycho- educational program that explores the roots of addiction, depression, and self destructive behaviors to enable clients to complete their recovery and succeed in the community. The goal of this core principle is to help people at the stage where they are at. As opposed a criminal justice model or sanction-based approach, the public health model relies on education, peer support, and methods that promote primary and secondary forms of prevention (such as relapse prevention).
Relapse Prevention: Relapse prevention is incorporated into many aspects of ARRIVE’s program, from topics covered in counseling and group sessions, to the director’s talk on “the beast within,” which helps people recognize those things which make them want to give up, to use again, and to hurt themselves. For this struggling with addiction, relapse prevention becomes a central, if not, the central goal.
Peer model: Peer models have been central to public health interventions and is central to the work of ARRIVE. Most staff have been drug users and /or have been affected by HIV/AIDS. Clients see other people who have been through the same thing as them as more legitimate authorities and this can have a big impact on their sense of self, and belief in change.
Objective 3: Assessment of Client Outcomes
In this section we provide data on programmatic outcomes. All the data for this section, with the exception of the retention data reviewed first, comes from the follow up interviews conducted on 27 clients, 4 to 6 week following completion of the program. In addition to this, are client narratives from the various focus groups we conducted. We assessed ARRIVE’s impact on several key outcomes – drug use, HIV care and attitudes, social adaptation, self awareness, personal attitudes, and stigma. Clients come to ARRIVE with many different motivations and a diverse set of issues for which they are seeking help. Therefore, outcomes have to be understood within the context of each client. Reduced drug use, for example, is only relevant for those who had a drug use problem when they came to ARRIVE (whether it’s recent drug use or not). Therefore, we present drug use data for only those clients that reported a recent history of drug use. There are also some clients that come to ARRIVE, not for help with any problem that they’re their currently struggling with, but rather for help to advance themselves in careers in the fields of HIV counseling or drug treatment. Many of them have overcome personal issues of addiction or stigma related to HIV and want to learn more, improve their resumes, and obtain the ARRIVE certificate. For the purposes of the evaluation, if they expressed substantial benefit from ARRIVE in this regard, we take this as a positive programmatic outcome. Furthermore, there is the important potential of these clients to disseminate ARRIVE’s model beyond the walls of Exponents, and this is an intangible outcome that can not be assessed here, but needs to be considered for future research. Finally, we review evidence that for some clients, they came to ARRIVE with a specific motive (say HIV education) but benefited substantially in other ways (a better understanding of addiction, which helps them better understand a family member’s drug problem). First, we review a key outcome for any service program, retention rate.
Retention
Retention rate is a key outcome because it is a clear indication of a program’s ability to keep clients engaged and exposed to services. Retention is particularly relevant for understanding how clients experience ARRIVE since it requires all day attendance, three days a week, over a twelve-month period. Clients who miss three or more classes are not allowed to graduate. Furthermore, it’s important to highlight the fact that ARRIVE is not a mandated program. 95 Clients originally signed up for the ARRIVE’s 102nd cycle (and participated in an intake interview). Of those, 77 started the program. We take the 77 as the total ARRIVE cycle. Of those 77, 65 completed the program, a retention rate of 87%. This is a very high retention rate and should be seen as a key programmatic outcome.
Drug use
Abstinence and Reduced drug use – The findings on drug use from the follow up interviews coincide well with ARRIVE’s client data. Among those who were interviewed, 30% had been using in the six months prior to attending ARRIVE and 15% had been using 30 to 90 days prior to admission. Many of the 30% that had ceased using in the past six months were in some form of drug treatment. One was on parole and another was in a mandated drug court program. Table 3 presents a schematic summary of outcome data collected on these groups. Among the 27 clients who we conducted a follow up interview on, four (15%) reported current drug use within the month prior to starting ARRIVE. Of those four, three had ceased using and had remained abstinent upon the follow up interview 16 to 18 weeks after starting ARRIVE. The other current drug user had cut their drug use in half and discussed being more stable in his life.
There were also powerful findings from the focus group on drug use outcomes. In a group with four clients, one person discussed at length how he had never had any real success in other treatment programs, including AA and NA. He was currently attending both, even while still using, and admitted to a history of serious drug problems. He was the only one among the four who had actively been using when he entered ARRIVE 1 year ago. He stopped using and talked about how this was the first time in his life he had been abstinent, and had not used in almost a year. ARRIVE’S atmosphere of acceptance was key to his success and dramatic growth: “I feel like I fit in this place. Nobody’s judging me. I feel like I’m in a big family. It’s like a home. I’m pretty sure this program is keeping me sober, keeping me on track.” He talked about how ARRIVE “gives me a sense of purpose” and talked about his plans to become a drug abuse counselor.
Understanding of Drug use and Addiction – Among the follow up sample, 42% described their drug, either past or current, as a “tremendous problem,” and all of these had attended multiple treatment programs (range 2 to 10). By the time of these interviews ( after graduation) 85% of clients reported a better understanding of their own drug use. Many of these expressed a much deeper understanding of how their addiction worked, why they kept on using, why it was so difficult to stop, and how to identify the triggers that place them at risk of relapse. It’s important to highlight that many who reported a greater understanding had been abstinent for some time. On a scale from 1 (not better understanding) to 10 (much greater understanding), the average response was 8.6, and half the clients gave a 10 as their response. Even without being asked, many clients discussed how they had benefited from ARRIVE around their drug use. This includes, learning about relapse triggers, the importance of having support networks, realizing that their own drug use was often a form of medicating their emotional pain, how it helped them understand how their own thinking contributed to their relapses and their inability to stop using and to make new decisions. One client said he realized now “how his drug use was killing him”. Others mentioned how no other programs gave them such factual information about how drugs actually affect the brain and the body - another client described this aspect of ARRIVE as “phenomenal.”
Drug use stigma – The third finding that provides evidence of positive drug use outcomes has to do with stigma. Among past or current drug users that participated in focus groups, stigma was a recurring theme. For many, it affected them very deeply- many talked about how they felt “branded,” and that despite years of abstinence and stability, they still felt the mistrust of others and a sense that they were “less than others.” Among past or current drug users interviewed, 85% reported having feelings of shame and stigma prior to ARRIVE. When asked how they felt now (at the time of the interview), 71% said they were better able to deal with their stigma and that it didn’t affect them as much anymore: 57% said they were “much better able” and 14% said they were “somewhat better able” to deal with any stigma they had.
HIV/AIDS
Among HIV positive clients followed up for interviews, 30% reported improvements in their ability to deal with their HIV status. This included their ability to either address their health care needs and to adhere to their HIV medication and their ability to deal emotionally with their disease (e.g., disclosing their status to others, better able to deal with feelings of anger and depression). This number, however, includes many HIV positive clients who attended ARRIVE primarily for employment reasons - individuals who tended to be very stable and were either already employed and working in the field of HIV or addiction or in training to do so (some for many years).
Coping with HIV status – A key objective behind the ARRIVE model is to create an open and accepting environment that encourages clients to address difficult emotional issues which typically lie at the heart of their personal struggles. There is ample evidence, from both the focus groups and follow up interviews, that this goal is being met. Narratives about the openness of the ARRIVE program was probably one of the most consistent findings of the study and for many clients, this seems to have translated into tangible outcomes for clients. Roughly half of all HIV positive clients (45%) reported having problems dealing with their HIV status when they came to ARRIVE: 22% said it was extremely difficult, and 38% said it was very difficult to be able to cope emotionally with their disease. Upon follow up, only 14% said it was somewhat difficult and nobody said it was extremely difficult. Therefore, most clients that had problems dealing with their HIV status prior to ARRIVE reported substantial improvements, emotionally or in their health-related behavior, after ARRIVE.
Disclosing HIV status to others – Another key indicator of client’s ability to better cope with their HIV/AIDS was a greater openness about their status to friends and family. 44% reported having problems disclosing their status to friends and family (33% extremely difficult and 11% very difficult). Upon follow up interview, 14% said they found it very difficult to disclose their status (nobody said it was extremely difficult). In total, 86% said they had no problem at all disclosing their status after going through the ARRIVE program. More importantly, the growth clients voiced was often dramatic. One woman said she had been very afraid of disclosing her HIV status at the residential home she was living in: “Arrive has helped me come out.” When she saw others who were open about it, she felt it was ok to disclose as well, and finally did so at the residential home. She talked about how it was “such a huge burden that was lifted off her back. I feel like I’m not alone.” Others talked about how they learned how to accept the disease and feel less fear, stigma, and shame about it.
Cognitive Shift and Global Life Changes
The final outcomes assessed are more difficult to measure and need to be approached more qualitatively. This is because they are more global and holistic in nature (rather than talking about a change in measurable behavior or an attitude on a scale), and have to do more with client’s emotional well-being, sense of self, and their relationships. Despite the difficulty in capturing this in an evaluation, it is a key outcome to assess. The question we addressed here is: Is there evidence that client’s lives have changed for the better, and that they have made a change in how they see themselves, their drug use, their disease, and their relationship with others. We adopt the term “cognitive shift” used by ARRIVE management staff to describe this.
The final question in the follow up interviews asked clients: “Is there anything different about your life, how you feel about your self, or other things such as your personal relationships or employment that has change since ARRIVE? Roughly a quarter (26%) of the sample answered this question in ways that reflect some type of cognitive shift and global life changes, often discussing dramatic personal or life changes, that reflected improvements in the way they feel about themselves, their families, and their prospects and aspirations. It’s important to emphasize that we only included narratives where changes were reported across multiple dimensions or when it was a global assessment about their lives. For example, several clients mentioned only that their relationships had improved, and this was not considered as evidence of cognitive shift.
Narratives that were included as evidence of this include, for example, one client, who said, “It took me to a new level; I want to focus on school and be a motivational speaker now, and talk about HIV to others. Another client said, “It motivated me to go back to school and get a career. I have a brand new mind, brand new heart. I feel like it's ok, like I could do this. It’s been a blessing in my life.” One client had never disclosed his HIV status to his family (diagnosed 15 years ago) and did so for the first time while attending ARRIVE. He was not employed before, and had enrolled to get drug treatment certificate. He said, “everyday I grow. I learned about the virus, how to take meds. It was a problem before, but everything is great now, nothing's stopping me now.” Another client said, “this [completing ARRIVE] was a great accomplishment for me. I'm a great starter, but a horrible finisher. Before, I didn't really know what I wanted to do.” Finally, another person’s succinct narrative we also taken as evidence of cognitive shift, “I feel more positive about everything.”
Summary of Program Outcomes in Key Areas
Drug Use Outcomes
Abstinence from drug use – 15%of those interviewed (4 out of 27) were active drug users at the time they entered the program: of these, 3 out the four had been abstinent during their participation in ARRIVE and had remained abstinent four to six week after graduating from the program. The other client had reduced their drug use (by as much as half).
Better understanding of drug addiction – Clients were asked if their understanding of their drug use or of drug use in general, improved while in ARRIVE. On a scale from 1 to 10 (where 10 = much greater understanding, and 1 = no change) the average response was 8.6; half the sample gave a 10 on this question. Clients were highly expressive with regard to how much they had learned about their own drug use and the drug use of family members (for those with no history of drug use).
HIV/AIDS Outcomes
Better able to deal with stigma resulting from their drug use – 71% of current or former drug users said they where now either much better (57% ) or somewhat better (14%) able to deal with the stigma they had experienced in the past resulting from their drug use.
Better able to emotionally deal with their HIV status – Among HIV positive clients, 55% said it was either extremely difficult (22%) or very difficult (33%) emotionally, to deal with their HIV status Prior to coming to ARRIVE. Upon follow up, only 14% had said it was still very difficult to deal with their HIV status. In contrast, 86% percent said it was not difficult at all anymore to deal with their HIV status.
Better able to disclose or discuss HIV status with others – 44% had problems disclosing their HIV status to others prior to ARRIVE (33% extremely difficult; 11% very difficult). After ARRIVE, only 14% found it very difficult to still disclose. 86% said they did not have any difficulty at all anymore in disclosing.
Better able to take HIV medications and deal with health care needs – Prior to ARRIVE, only 33% of the sample said they had “few or no problems” in keeping up with their HIV medications and health care needs. After ARRIVE, this figure went up to 70%.
Evidence of Life Change
At follow up 26 % of clients discussed dramatic personal or life changes, that reflected improvements in the way they feel about themselves, their families, and their prospects and aspirations. The following narratives reflect the changes that clients discussed:
¨“It motivated me to go back to school and get a career. I have a brand new mind, brand new heart. I feel like it's ok, like I could do this. It’s been a blessing in my life.
¨“It took me to a new level; I want to focus on school and be a motivational speaker now, and talk about HIV to others.
¨One client had never disclosed his HIV status to his family (diagnosed 15 years ago) and did so for the first time while attending ARRIVE. He was not employed before, and had enrolled to get drug treatment certificate; “everyday I grow. I learned about the virus, how to take meds. It was a problem before, but everything is great now, nothing's stopping me now.”
¨This [completing ARRIVE] was a great accomplishment for me. I'm a great starter, but a horrible finisher. Before, I didn't really know what I wanted to do.”
